Healthcare Provider Details

I. General information

NPI: 1427474568
Provider Name (Legal Business Name): MIKI R MOFFITT RN, BSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 LLANO ST
AZTEC NM
87410-2172
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 505-334-3404
  • Fax:
Mailing address:
  • Phone: 505-334-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR41419
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number85672
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: