Healthcare Provider Details

I. General information

NPI: 1093175523
Provider Name (Legal Business Name): DOROTHY M PORTILLO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOROTHY MARTINEZ PORTILLO FNP-C

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 W AMADOR AVE STE D
LAS CRUCES NM
88005-2739
US

IV. Provider business mailing address

999 W AMADOR AVE STE D
LAS CRUCES NM
88005-2739
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5482
  • Fax: 575-525-3542
Mailing address:
  • Phone: 575-527-5482
  • Fax: 575-525-3542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02857
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: