Healthcare Provider Details

I. General information

NPI: 1407660889
Provider Name (Legal Business Name): MARIAN NEZ CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DR
TOHAJIILEE NM
87026
US

IV. Provider business mailing address

129 MEDICINE HORSE DR PO BOX 3338
TOHAJIILEE NM
87026
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2307
  • Fax: 505-908-2306
Mailing address:
  • Phone: 505-908-2307
  • Fax: 505-908-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberS1-026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: