Healthcare Provider Details

I. General information

NPI: 1720925738
Provider Name (Legal Business Name): TRACI RENE MAYNEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N WATER ST
LAS CRUCES NM
88001-1219
US

IV. Provider business mailing address

4281 NAMBE CT
LAS CRUCES NM
88011-4287
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-2924
  • Fax:
Mailing address:
  • Phone: 575-644-2924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-314630
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: