Healthcare Provider Details

I. General information

NPI: 1710580865
Provider Name (Legal Business Name): MEGAN JAYLYN VELASQUEZ-BACA MSN-APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 ROAD 4599
BLANCO NM
87412-8741
US

IV. Provider business mailing address

PO BOX 305
BLANCO NM
87412-0304
US

V. Phone/Fax

Practice location:
  • Phone: 505-516-4909
  • Fax:
Mailing address:
  • Phone: 505-516-4909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62051
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: