Healthcare Provider Details

I. General information

NPI: 1255752127
Provider Name (Legal Business Name): MRS. CAROLYN MARIE OWENS I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 CAMBRIDGE AVE
HAGERMAN NM
88232-9610
US

IV. Provider business mailing address

406 CAMBRIDGE AVE
HAGERMAN NM
88232-9610
US

V. Phone/Fax

Practice location:
  • Phone: 575-752-0001
  • Fax: 575-752-3255
Mailing address:
  • Phone: 575-752-0001
  • Fax: 575-752-3255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRO9981
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: