Healthcare Provider Details

I. General information

NPI: 1184864043
Provider Name (Legal Business Name): MARLA D. JIM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARLA D. HOWE RN

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DRIVE
CANONCITO NM
87026
US

IV. Provider business mailing address

PO BOX 3338
TOHAJIILEE NM
87026-3338
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2307
  • Fax: 505-908-2310
Mailing address:
  • Phone: 505-908-2307
  • Fax: 505-908-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN-69198
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: