Healthcare Provider Details

I. General information

NPI: 1215713664
Provider Name (Legal Business Name): MIKAYLA BAH TINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2023
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CALLE LIBRA CT
TIJERAS NM
87059-7372
US

IV. Provider business mailing address

10 CALLE LIBRA CT
TIJERAS NM
87059-7372
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-4174
  • Fax:
Mailing address:
  • Phone: 505-670-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2026-1187
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: