Healthcare Provider Details

I. General information

NPI: 1134586944
Provider Name (Legal Business Name): KRISTA VILLA MAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 MORNING STAR DR UNIT 3701
LAS CRUCES NM
88011-1783
US

IV. Provider business mailing address

3650 MORNING STAR DR UNIT 3701
LAS CRUCES NM
88011-1783
US

V. Phone/Fax

Practice location:
  • Phone: 575-703-6156
  • Fax:
Mailing address:
  • Phone: 575-703-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT859
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: