Healthcare Provider Details

I. General information

NPI: 1326441346
Provider Name (Legal Business Name): LADONNA LEE CHACON AGPCNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2014
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E MIEL DE LUNA AVE
TUCUMCARI NM
88401-3828
US

IV. Provider business mailing address

402 E MIEL DE LUNA AVE
TUCUMCARI NM
88401-3828
US

V. Phone/Fax

Practice location:
  • Phone: 575-461-7100
  • Fax: 575-461-7101
Mailing address:
  • Phone: 575-461-7100
  • Fax: 575-461-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR32046
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP-02602
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP-02602
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP-02602
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: