Healthcare Provider Details

I. General information

NPI: 1699196659
Provider Name (Legal Business Name): PHYLLIS ROBERTS R. N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 W PICACHO AVE
LAS CRUCES NM
88007-4823
US

IV. Provider business mailing address

4501 W PICACHO AVE
LAS CRUCES NM
88007-4823
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-9606
  • Fax: 575-527-9612
Mailing address:
  • Phone: 575-527-5884
  • Fax: 575-527-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR18834
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: