Healthcare Provider Details

I. General information

NPI: 1639725401
Provider Name (Legal Business Name): DIANE WRIGHT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE ORTEGA

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W COUNTRY CLUB RD STE 130
ROSWELL NM
88201-5249
US

IV. Provider business mailing address

300 W COUNTRY CLUB RD STE 130
ROSWELL NM
88201-5249
US

V. Phone/Fax

Practice location:
  • Phone: 575-625-2669
  • Fax: 575-624-4632
Mailing address:
  • Phone: 575-625-2669
  • Fax: 575-624-4632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57511
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: