Healthcare Provider Details

I. General information

NPI: 1023580073
Provider Name (Legal Business Name): LETICIA MEDRANO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 23RD ST
ROSWELL NM
88201-6471
US

IV. Provider business mailing address

115 E 23RD ST
ROSWELL NM
88201-6471
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-1292
  • Fax: 575-624-4836
Mailing address:
  • Phone: 575-625-1292
  • Fax: 575-624-4836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54775
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: