Healthcare Provider Details

I. General information

NPI: 1740070358
Provider Name (Legal Business Name): FALLON MOODY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W COUNTRY CLUB RD
ROSWELL NM
88201-5892
US

IV. Provider business mailing address

PO BOX 2608
ROSWELL NM
88202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-6322
  • Fax: 575-622-6888
Mailing address:
  • Phone: 575-622-6322
  • Fax: 575-622-6888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number56553
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: