Healthcare Provider Details

I. General information

NPI: 1245026558
Provider Name (Legal Business Name): KELSEY ERICA LUCILLE STEVENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

332 CLARA LN
RIO COMMUNITIES NM
87002-6033
US

V. Phone/Fax

Practice location:
  • Phone: 505-859-2986
  • Fax:
Mailing address:
  • Phone: 505-859-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: