Healthcare Provider Details

I. General information

NPI: 1245602127
Provider Name (Legal Business Name): JESSICA DALTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

538 COUNTY ROAD 6100
KIRTLAND NM
87417-9317
US

IV. Provider business mailing address

538 COUNTY ROAD 6100
KIRTLAND NM
87417-9317
US

V. Phone/Fax

Practice location:
  • Phone: 505-598-6114
  • Fax: 505-598-9562
Mailing address:
  • Phone: 505-598-6114
  • Fax: 505-598-9562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR66047
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: