1578028874 NPI number — AILEEN LARDIS CRNP

Table of content: AILEEN LARDIS CRNP (NPI 1578028874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578028874 NPI number — AILEEN LARDIS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARDIS
Provider First Name:
AILEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILLIGAN
Provider Other First Name:
AILEEN
Provider Other Middle Name:
COLLETTE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578028874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 MEDICAL PKWY STE 304
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-3745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
105-739-5304
Provider Business Practice Location Address Fax Number:
664-204-7229
Provider Enumeration Date:
01/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  R175578 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 772153600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 791003 . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 792305 . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: CY310018 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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