Healthcare Provider Details

I. General information

NPI: 1972371797
Provider Name (Legal Business Name): EDITH MORAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 S SANTA BARBARA ST
DEMING NM
88030-5361
US

IV. Provider business mailing address

1419 S SANTA BARBARA ST
DEMING NM
88030-5361
US

V. Phone/Fax

Practice location:
  • Phone: 575-936-4227
  • Fax: 575-936-4658
Mailing address:
  • Phone: 575-936-4227
  • Fax: 575-936-4658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: