MEDICARE: LYDIA MACKLIN CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	R37028	NM
2	363LF0000X	Family Nurse Practitioner	CNP00803	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	343502805	OTHER	NM	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003812553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA MACKLIN CNP

Provider Business Mailing Address
First Line	:	385 CALLE DE ALEGRA
Second Line	:	BLDG A
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3423
Country	:	US
Telephone Number	:	575-526-1105
Fax Number	:	575-524-4266

Provider Business Practice Location Address
First Line	:	855 ANTHONY DR
Second Line	:
City	:	ANTHONY
State	:	NM
Zip	:	88021
Country	:	US
Telephone Number	:	575-882-5706
Fax Number	:	575-882-2909

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	08/28/2018

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