Healthcare Provider Details

I. General information

NPI: 1164850665
Provider Name (Legal Business Name): MARY PRISCILLA LEONG AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 E LOHMAN AVE STE 122
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

V. Phone/Fax

Practice location:
  • Phone: 575-556-6855
  • Fax: 575-556-6859
Mailing address:
  • Phone: 575-532-5455
  • Fax: 575-532-5641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP-02271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: