Healthcare Provider Details

I. General information

NPI: 1336063940
Provider Name (Legal Business Name): ELLA MAE IRVIN-MARCINAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S PEARL ST APT 3
DEMING NM
88030-4702
US

IV. Provider business mailing address

1111 S PEARL ST APT 3
DEMING NM
88030-4702
US

V. Phone/Fax

Practice location:
  • Phone: 575-997-8645
  • Fax:
Mailing address:
  • Phone: 575-997-8645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number2080P0008X
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: