Healthcare Provider Details

I. General information

NPI: 1063940203
Provider Name (Legal Business Name): ASHLEY DEANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2017
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 LOS LENTES ROAD NE
LOS LUNAS NM
87031
US

IV. Provider business mailing address

1455 REDONDO CT
LOS LUNAS NM
87031-9058
US

V. Phone/Fax

Practice location:
  • Phone: 505-974-5890
  • Fax:
Mailing address:
  • Phone: 505-573-3809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: