Healthcare Provider Details

I. General information

NPI: 1568291540
Provider Name (Legal Business Name): REAGAN KREIDLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 E 30TH ST
FARMINGTON NM
87402-8805
US

IV. Provider business mailing address

4000 CRESTRIDGE DR
FARMINGTON NM
87401-9310
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8617
  • Fax: 855-290-2205
Mailing address:
  • Phone: 505-402-8234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number64233
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: