Healthcare Provider Details

I. General information

NPI: 1609683697
Provider Name (Legal Business Name): AVALON SANTANA ZAKAZAKINA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 LIPAN AVENUE
MESCALERO NM
88340
US

IV. Provider business mailing address

82 PIONEER DR
TIMBERON NM
88350-9678
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4802
  • Fax:
Mailing address:
  • Phone: 575-987-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number76328
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: