Healthcare Provider Details

I. General information

NPI: 1629938873
Provider Name (Legal Business Name): MARYLOU BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

IV. Provider business mailing address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8707
  • Fax: 505-989-3536
Mailing address:
  • Phone: 505-577-4543
  • Fax: 505-989-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number85944
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: