Healthcare Provider Details

I. General information

NPI: 1851718936
Provider Name (Legal Business Name): NIKOLE LEMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 4TH AVE
RATON NM
87740-2643
US

IV. Provider business mailing address

413 SIPAPU ST
TAOS NM
87571-6489
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-2754
  • Fax:
Mailing address:
  • Phone: 575-758-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: