Healthcare Provider Details

I. General information

NPI: 1477162683
Provider Name (Legal Business Name): GEMA VILLANUEVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2020
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SUTTER PL
CLOVIS NM
88101-4611
US

IV. Provider business mailing address

1701 S AVENUE A
PORTALES NM
88130-7347
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-4445
  • Fax:
Mailing address:
  • Phone: 575-607-8475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: