Basic Information
| Provider Information | |||||||||
| NPI: | 1306856166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILLY | ||||||||
| FirstName: | LITA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAILLY | ||||||||
| OtherFirstName: | LITA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1217 BONITA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872950 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1217 BONITA ST | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870202103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872950 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R029543 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP081328 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 335260099 | 05 | ME | MEDICAID |