Healthcare Provider Details

I. General information

NPI: 1356218952
Provider Name (Legal Business Name): MARILYN NIOMIE FRAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5065 MCNUTT RD
SANTA TERESA NM
88008-9442
US

IV. Provider business mailing address

4600 FAIRBANKS DR APT 1117
EL PASO TX
79924-3746
US

V. Phone/Fax

Practice location:
  • Phone: 915-740-4894
  • Fax:
Mailing address:
  • Phone: 915-740-4894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0415
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: