Healthcare Provider Details

I. General information

NPI: 1629706254
Provider Name (Legal Business Name): MARIAH KAY LASLEY-MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N BERGIN LN
BLOOMFIELD NM
87413-6729
US

IV. Provider business mailing address

325 N BERGIN LN
BLOOMFIELD NM
87413-6729
US

V. Phone/Fax

Practice location:
  • Phone: 505-632-4856
  • Fax:
Mailing address:
  • Phone: 505-632-4856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN-84602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: