Healthcare Provider Details

I. General information

NPI: 1346454832
Provider Name (Legal Business Name): STELLA M AVENA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 SOUTHERN BLVD SE SUITE 1106
RIO RANCHO NM
87124-2080
US

IV. Provider business mailing address

3715 SOUTHERN BLVD SE
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6047
  • Fax: 212-953-1353
Mailing address:
  • Phone: 505-462-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011122
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3788
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: