Healthcare Provider Details

I. General information

NPI: 1407567944
Provider Name (Legal Business Name): ALICIA DAWN HISTIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 PINSBAARI
PUEBLO OF ACOMA NM
87034
US

IV. Provider business mailing address

47 PINSBAARI DR.
PUEBLO OF ACOMA NM
87034
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5145
  • Fax:
Mailing address:
  • Phone: 505-552-5145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: