Healthcare Provider Details

I. General information

NPI: 1376265819
Provider Name (Legal Business Name): EMILY MOLLER RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BERTHA RD STE B
TAOS NM
87571-7148
US

IV. Provider business mailing address

PO BOX 144
ARROYO SECO NM
87514-0144
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax: 575-751-7237
Mailing address:
  • Phone: 203-297-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number814786
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95192614
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95021947
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number77964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: