Healthcare Provider Details

I. General information

NPI: 1275197436
Provider Name (Legal Business Name): MELANIE GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

IV. Provider business mailing address

1621 SALT RIVER CT NE
RIO RANCHO NM
87144-6413
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-1239
  • Fax: 888-746-4761
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1604
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: