Healthcare Provider Details

I. General information

NPI: 1700567864
Provider Name (Legal Business Name): NICOLE MARIE LEDESMA-GOINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 STONE CANYON DR
LAS CRUCES NM
88011-0979
US

IV. Provider business mailing address

776 STONE CANYON DR
LAS CRUCES NM
88011-0979
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-4235
  • Fax:
Mailing address:
  • Phone: 575-202-4235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number74939
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: