Healthcare Provider Details

I. General information

NPI: 1790490928
Provider Name (Legal Business Name): JENNIFER AVINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 W 21ST ST
CLOVIS NM
88101-4149
US

IV. Provider business mailing address

912 W 21ST ST
CLOVIS NM
88101-4149
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-9000
  • Fax: 575-935-1002
Mailing address:
  • Phone: 575-935-9000
  • Fax: 575-935-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1107768
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: