Healthcare Provider Details

I. General information

NPI: 1477043594
Provider Name (Legal Business Name): MARTHA ELIA REYES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 11/27/2023
Certification Date: 06/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 E ROOSEVELT AVE
GRANTS NM
87020-2245
US

IV. Provider business mailing address

20 PRESERVE DR
NEWNAN GA
30263-2283
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number60147
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: