Healthcare Provider Details

I. General information

NPI: 1669246443
Provider Name (Legal Business Name): TENNILLE ALEXA MARRUJO-MOCTEZUMA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4733 SALADO CREEK ST
LAS CRUCES NM
88012-5072
US

IV. Provider business mailing address

4733 SALADO CREEK ST
LAS CRUCES NM
88012-5072
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-9254
  • Fax:
Mailing address:
  • Phone: 575-644-9254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number81131
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: