Healthcare Provider Details

I. General information

NPI: 1851584213
Provider Name (Legal Business Name): MELISSA Y WYACO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40 EXIT 102
SAN FIDEL NM
87049-0130
US

IV. Provider business mailing address

PO BOX 130
SAN FIDEL NM
87049-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5324
  • Fax: 505-552-5811
Mailing address:
  • Phone: 505-552-5324
  • Fax: 505-552-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR29030
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR29030
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: