Healthcare Provider Details

I. General information

NPI: 1861018236
Provider Name (Legal Business Name): KIKINA WONG APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4351 E LOHMAN AVE STE 208
LAS CRUCES NM
88011-8260
US

IV. Provider business mailing address

4351 E LOHMAN AVE STE 208
LAS CRUCES NM
88011-8260
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-8895
  • Fax:
Mailing address:
  • Phone: 575-556-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number830145
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number64384
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: