Healthcare Provider Details

I. General information

NPI: 1841066727
Provider Name (Legal Business Name): LEANDRA NICOLE TRUJILLO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MAIN ST NW
LOS LUNAS NM
87031-4812
US

IV. Provider business mailing address

1028 WALNUT CT SE
LOS LUNAS NM
87031-9251
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4368
  • Fax:
Mailing address:
  • Phone: 505-908-4531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1044
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: