Healthcare Provider Details

I. General information

NPI: 1134039035
Provider Name (Legal Business Name): MARISSA TEAH VELASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOUGLAS AVE
LAS VEGAS NM
87701-3928
US

IV. Provider business mailing address

742 DORA CELESTE DR
LAS VEGAS NM
87701-5112
US

V. Phone/Fax

Practice location:
  • Phone: 505-429-3951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number57202
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: