Provider Demographics
NPI:1699116632
Name:BAILEY, ELIZABETH ANN
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 S DUCK LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1422
Mailing Address - Country:US
Mailing Address - Phone:248-762-9635
Mailing Address - Fax:
Practice Address - Street 1:1640 S DUCK LAKE RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1422
Practice Address - Country:US
Practice Address - Phone:248-762-9635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2013-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16930133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered