Healthcare Provider Details

I. General information

NPI: 1245500347
Provider Name (Legal Business Name): LETITIA M. HENLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#22 CIELO VISTA RD. INDIVIDUAL CLIENT HOMES;
VADITO NM
87579
US

IV. Provider business mailing address

#22 CIELO VISTA RD
VADITO NM
87579
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-1756
  • Fax:
Mailing address:
  • Phone: 575-587-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number#5422
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: