Healthcare Provider Details

I. General information

NPI: 1891085262
Provider Name (Legal Business Name): STELLA ELIZABETH WILSON M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 STONE LAKE ROAD
DULCE NM
87528
US

IV. Provider business mailing address

500 STONE LAKE ROAD
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-7309
  • Fax: 575-759-7294
Mailing address:
  • Phone: 575-759-7309
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberTN 26432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: