Healthcare Provider Details

I. General information

NPI: 1396176319
Provider Name (Legal Business Name): SELENE MARIE LA MARCA AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2013
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8268
US

IV. Provider business mailing address

3821 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4679
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-5752
  • Fax: 575-522-5722
Mailing address:
  • Phone: 505-998-7401
  • Fax: 505-998-7740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-02303
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP-02303
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: