Provider Demographics
NPI:1447797758
Name:LIFTED CLINICAL PRACTICE, PLLC
Entity Type:Organization
Organization Name:LIFTED CLINICAL PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:FUNMILAYO
Authorized Official - Middle Name:
Authorized Official - Last Name:AINA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,FNP-C
Authorized Official - Phone:505-430-0760
Mailing Address - Street 1:2801 RODEO RD STE C14
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-6503
Mailing Address - Country:US
Mailing Address - Phone:505-430-0760
Mailing Address - Fax:866-354-3833
Practice Address - Street 1:2801 RODEO RD STE C14
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-6503
Practice Address - Country:US
Practice Address - Phone:505-430-0760
Practice Address - Fax:866-354-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP123182261QC1500X
TX688447261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health