Healthcare Provider Details

I. General information

NPI: 1760961908
Provider Name (Legal Business Name): HALCYON HEALTH OF THE SOUTHWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 12/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 CALIFORNIA AVE STE B
LAS CRUCES NM
88001
US

IV. Provider business mailing address

1355 CALIFORNIA AVE STE B
LAS CRUCES NM
88001-4187
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-8951
  • Fax: 575-366-8011
Mailing address:
  • Phone: 575-523-8951
  • Fax: 575-366-8011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-02392
License Number StateNM

VIII. Authorized Official

Name: MISTI LYNN
Title or Position: OWNER / PROVIDER
Credential: FNP-C
Phone: 931-636-6648