Healthcare Provider Details

I. General information

NPI: 1073272357
Provider Name (Legal Business Name): IRIDIANA MEJIA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 ALAMO AVE SE
ALBUQUERQUE NM
87106-3225
US

IV. Provider business mailing address

2350 ALAMO AVE SE
ALBUQUERQUE NM
87106-3225
US

V. Phone/Fax

Practice location:
  • Phone: 505-364-2122
  • Fax: 505-272-7026
Mailing address:
  • Phone: 505-364-2122
  • Fax: 505-272-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1077
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: