MEDICARE: SHIRLEY DELORISE BALTRIP CNA CERTIFICATE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide
2	302R00000X	Health Maintenance Organization	0749881	SC

General Provider Information

NPI Number	:	1740515816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLEY DELORISE BALTRIP CNA CERTIFICATE

Provider Business Mailing Address
First Line	:	116 CREEK WAY LN
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-5720
Country	:	US
Telephone Number	:	803-409-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	5112 WAVING FLOWER DR
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-6269
Country	:	US
Telephone Number	:	702-695-6191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2009
Last Update Date	:	06/05/2019

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