=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336063940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLA MAE IRVIN-MARCINAK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2026
-----------------------------------------------------
Last Update Date | 08/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 S PEARL ST APT 3
-----------------------------------------------------
City | DEMING
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88030-4702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-997-8645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 S PEARL ST APT 3
-----------------------------------------------------
City | DEMING
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88030-4702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-997-8645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0008X
-----------------------------------------------------
Taxonomy Name | Pediatric Neurodevelopmental Disabilities Physician
-----------------------------------------------------
License Number | 2080P0008X
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------