Provider Demographics
NPI:1306856166
Name:BAILLY, LITA C (FNP)
Entity type:Individual
Prefix:
First Name:LITA
Middle Name:C
Last Name:BAILLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:LITA
Other - Middle Name:C
Other - Last Name:BAILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1217 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2103
Mailing Address - Country:US
Mailing Address - Phone:505-287-2950
Mailing Address - Fax:505-287-2403
Practice Address - Street 1:1217 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2103
Practice Address - Country:US
Practice Address - Phone:505-287-2950
Practice Address - Fax:505-287-2403
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER029543363LF0000X
MEAP081328363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME335260099Medicaid
MEP52461Medicare UPIN
ME335260099Medicaid