Healthcare Provider Details

I. General information

NPI: 1497583652
Provider Name (Legal Business Name): MARQUITA HERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7013 4TH ST NW STE E
LOS RANCHOS NM
87107-6639
US

IV. Provider business mailing address

7013 4TH ST NW STE E
LOS RANCHOS NM
87107-6639
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-9340
  • Fax:
Mailing address:
  • Phone: 505-977-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-2024-0151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: