Healthcare Provider Details

I. General information

NPI: 1912142316
Provider Name (Legal Business Name): VIRGINIA NICHOLLS ALDEA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2008
Last Update Date: 12/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N PEARL ST
DEMING NM
88030-3835
US

IV. Provider business mailing address

3308 GILA CT
DEMING NM
88030-8673
US

V. Phone/Fax

Practice location:
  • Phone: 575-544-4663
  • Fax: 575-544-4665
Mailing address:
  • Phone: 575-545-1913
  • Fax: 575-546-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2427
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number111412
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: