Healthcare Provider Details

I. General information

NPI: 1760212351
Provider Name (Legal Business Name): MELISSA ANNE PORTILLO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N ALAMEDA BLVD
LAS CRUCES NM
88005-2610
US

IV. Provider business mailing address

2608 SAN ANDRES DR
LAS CRUCES NM
88007-8020
US

V. Phone/Fax

Practice location:
  • Phone: 505-993-2673
  • Fax:
Mailing address:
  • Phone: 915-799-1456
  • Fax: 915-564-6104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number78040
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: