MEDICARE: MAILIN ISABEL QUINONES JIMENEZ APRN

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	207Q00000X	Family Medicine Physician	11023307	FL
2	363LF0000X	Family Nurse Practitioner	11023307	FL
3	363LF0000X	Family Nurse Practitioner	71568	NM

General Provider Information

NPI Number	:	1013622836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAILIN ISABEL QUINONES JIMENEZ APRN

Provider Business Mailing Address
First Line	:	203 POPLAR ST
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220-6332
Country	:	US
Telephone Number	:	786-501-3043
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 W PIERCE ST STE 101
Second Line	:
City	:	CARLSBAD
State	:	NM
Zip	:	88220-3517
Country	:	US
Telephone Number	:	575-628-0107
Fax Number	:

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

Provider Enumeration Date	:	01/16/2023
Last Update Date	:	05/19/2023

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