Provider Demographics
NPI:1740515816
Name:BALTRIP, SHIRLEY DELORISE (CNA CERTIFICATE)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:DELORISE
Last Name:BALTRIP
Suffix:
Gender:F
Credentials:CNA CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CREEK WAY LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-5720
Mailing Address - Country:US
Mailing Address - Phone:803-409-9444
Mailing Address - Fax:
Practice Address - Street 1:5112 WAVING FLOWER DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-6269
Practice Address - Country:US
Practice Address - Phone:702-695-6191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
SC0749881302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No374U00000XNursing Service Related ProvidersHome Health Aide