Provider Demographics
NPI:1437633005
Name:BAEZ, NILSA IVETTE
Entity Type:Individual
Prefix:MS
First Name:NILSA
Middle Name:IVETTE
Last Name:BAEZ
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 1:6140 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3891
Mailing Address - Country:US
Mailing Address - Phone:440-233-7232
Mailing Address - Fax:
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3891
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid