Healthcare Provider Details

I. General information

NPI: 1912410721
Provider Name (Legal Business Name): LAURA MASSEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S KNOXVILLE ST
PORTALES NM
88130-6100
US

IV. Provider business mailing address

201 S KNOXVILLE ST
PORTALES NM
88130-6100
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-7015
  • Fax: 575-356-8082
Mailing address:
  • Phone: 575-356-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR35114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: