Healthcare Provider Details

I. General information

NPI: 1669613568
Provider Name (Legal Business Name): MARY ANN NMN SPENCER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANN NMN LANEY CNP

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 8TH ST
LAS VEGAS NM
87701-4219
US

IV. Provider business mailing address

PO BOX 158
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-6788
  • Fax: 505-747-7396
Mailing address:
  • Phone: 505-753-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number464128
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAP126564
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberCNP-03110
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: