Healthcare Provider Details

I. General information

NPI: 1174391296
Provider Name (Legal Business Name): VANESSA MARIAH MEZA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANESSA MARIAH CASTILLO

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 BONITA ST
GRANTS NM
87020-2234
US

IV. Provider business mailing address

1423 E ROOSEVELT AVE
GRANTS NM
87020-2245
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-6500
  • Fax: 505-287-5393
Mailing address:
  • Phone: 505-287-5600
  • Fax: 505-287-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberS1-1368
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: