Healthcare Provider Details

I. General information

NPI: 1669921003
Provider Name (Legal Business Name): LAPRINCESS D TSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 W ANIMAS ST STE 101
FARMINGTON NM
87401-5616
US

IV. Provider business mailing address

PO BOX 6210
FARMINGTON NM
87499-6210
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-2880
  • Fax: 505-609-2882
Mailing address:
  • Phone: 505-609-6595
  • Fax: 505-609-6579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03007
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: