Healthcare Provider Details

I. General information

NPI: 1588287874
Provider Name (Legal Business Name): MARIELLE LAGAMAYO OPENA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 07/09/2023
Certification Date: 07/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

IV. Provider business mailing address

42121 US HIGHWAY 70
PORTALES NM
88130-9054
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-6652
  • Fax:
Mailing address:
  • Phone: 575-356-6652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2023-0338
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: