Healthcare Provider Details

I. General information

NPI: 1366811721
Provider Name (Legal Business Name): RUSSELL DAVID CORYELL CNP-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 S VALLEY DR STE B
LAS CRUCES NM
88005-3165
US

IV. Provider business mailing address

1455 S VALLEY DR STE B
LAS CRUCES NM
88005-3165
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-6992
  • Fax: 575-526-7983
Mailing address:
  • Phone: 575-526-6992
  • Fax: 575-526-7983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: