Healthcare Provider Details

I. General information

NPI: 1033646047
Provider Name (Legal Business Name): MIQUELLA ESPINOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 STATE ROAD 503 # 1A
SANTA FE NM
87506-9780
US

IV. Provider business mailing address

PO BOX 146
CHIMAYO NM
87522-0146
US

V. Phone/Fax

Practice location:
  • Phone: 505-692-5200
  • Fax:
Mailing address:
  • Phone: 505-692-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: