Healthcare Provider Details

I. General information

NPI: 1548109499
Provider Name (Legal Business Name): MS. CORRINA A MONTOWINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. CORRINA A MONTOWINE

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 N RIVERSIDE DR STE A
ESPANOLA NM
87532-2620
US

IV. Provider business mailing address

112 AVEH POE
NAMBE PUEBLO NM
87506-9713
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-4453
  • Fax:
Mailing address:
  • Phone: 505-692-0272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: