Provider Demographics
NPI:1770454688
Name:BAILLIS, CARLY MORGAN (MS, RD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:MORGAN
Last Name:BAILLIS
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 NEW DARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5609
Mailing Address - Country:US
Mailing Address - Phone:610-772-6641
Mailing Address - Fax:
Practice Address - Street 1:351 NEW DARLINGTON RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5609
Practice Address - Country:US
Practice Address - Phone:610-772-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86167924133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered