Healthcare Provider Details

I. General information

NPI: 1396098950
Provider Name (Legal Business Name): TAMMY RENEE DUVAL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 S SONOMA RANCH BLVD
LAS CRUCES NM
88011-1706
US

IV. Provider business mailing address

8408 ROCKY ACRES TRL
LAS CRUCES NM
88007
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-9330
  • Fax:
Mailing address:
  • Phone: 575-644-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number483
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: