Healthcare Provider Details

I. General information

NPI: 1013639830
Provider Name (Legal Business Name): LACY ANN RODRIGUEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 W 11TH ST
SILVER CITY NM
88061-5136
US

IV. Provider business mailing address

1387 BISON SPRING DR
LAS CRUCES NM
88012-5105
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1511
  • Fax:
Mailing address:
  • Phone: 575-574-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number69210
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: