Healthcare Provider Details

I. General information

NPI: 1538080957
Provider Name (Legal Business Name): MELISSA VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 WALDEN RD
CORRALES NM
87048-8369
US

IV. Provider business mailing address

80 WALDEN RD
CORRALES NM
87048-8369
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-7772
  • Fax: 505-212-4174
Mailing address:
  • Phone: 505-720-7772
  • Fax: 505-212-4174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16413
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: