Healthcare Provider Details

I. General information

NPI: 1083507396
Provider Name (Legal Business Name): CECILIA PINON PROVENCIO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 W OHARA RD
ANTHONY NM
88021-8844
US

IV. Provider business mailing address

2070 W OHARA RD
ANTHONY NM
88021-8844
US

V. Phone/Fax

Practice location:
  • Phone: 915-873-1781
  • Fax:
Mailing address:
  • Phone: 915-873-1781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1598
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: