Healthcare Provider Details

I. General information

NPI: 1285453498
Provider Name (Legal Business Name): MS. KEYA MERAH NKONOKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E. ROOSEVELT AVE
GRANTS NM
87020
US

IV. Provider business mailing address

1423 E. ROOSEVELT AVE
GRANTS NM
87020
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberSI-1652
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: