Healthcare Provider Details

I. General information

NPI: 1790453561
Provider Name (Legal Business Name): CROSS HEART CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 NORTH 4TH STREET
FORT SUMNER NM
88119-9411
US

IV. Provider business mailing address

PO BOX 928
FORT SUMNER NM
88119-0928
US

V. Phone/Fax

Practice location:
  • Phone: 575-355-2273
  • Fax:
Mailing address:
  • Phone: 575-355-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY MOLLY KENYON
Title or Position: OWNER PROVIDER
Credential: APRN-CNP
Phone: 575-355-2273