Healthcare Provider Details

I. General information

NPI: 1700393766
Provider Name (Legal Business Name): STACY JAQUE VIGIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 CHICO DR
LAS VEGAS NM
87701-9511
US

IV. Provider business mailing address

1264 RODEO RD
SANTA FE NM
87505-6816
US

V. Phone/Fax

Practice location:
  • Phone: 505-429-5508
  • Fax:
Mailing address:
  • Phone: 505-982-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberLPN-22383
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN-22383
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: