Healthcare Provider Details

I. General information

NPI: 1376536854
Provider Name (Legal Business Name): EDNA GAIL GUTIERREZ CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDNA GAIL JOHNSON

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N. MAIN
MELROSE NM
88124
US

IV. Provider business mailing address

PO BOX 299
PORTALES NM
88130-0299
US

V. Phone/Fax

Practice location:
  • Phone: 575-253-4373
  • Fax: 575-253-4575
Mailing address:
  • Phone: 575-356-6652
  • Fax: 575-359-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR30396
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00610
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: