Healthcare Provider Details

I. General information

NPI: 1306948658
Provider Name (Legal Business Name): WANDA J PONCIK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 S TELSHOR BLVD
LAS CRUCES NM
88011-5049
US

IV. Provider business mailing address

PO BOX 2278
LAS CRUCES NM
88004-2278
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-1919
  • Fax: 575-521-1676
Mailing address:
  • Phone: 575-521-1919
  • Fax: 575-521-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01117
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number508505
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: