Healthcare Provider Details

I. General information

NPI: 1053883306
Provider Name (Legal Business Name): GRACEFUL AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4402 SUPERSTITION DR
LAS CRUCES NM
88011-7503
US

IV. Provider business mailing address

PO BOX 13426
LAS CRUCES NM
88013-3426
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-3390
  • Fax:
Mailing address:
  • Phone: 575-621-3390
  • Fax: 575-993-5327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMY ELISE LOPEZ
Title or Position: OWNER
Credential: DNP
Phone: 575-621-3390