Healthcare Provider Details

I. General information

NPI: 1033619382
Provider Name (Legal Business Name): MICHELLE VAN ZELST PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1361 SARA WAY SE
RIO RANCHO NM
87124-0999
US

IV. Provider business mailing address

1361 SARA WAY SE
RIO RANCHO NM
87124-0999
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-3841
  • Fax: 505-891-7811
Mailing address:
  • Phone: 505-377-3841
  • Fax: 505-891-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA1331
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: