MEDICARE: MS. TAIWO T EGBETOLA RN

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	58514	NM

General Provider Information

NPI Number	:	1609560416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TAIWO T EGBETOLA RN

Provider Business Mailing Address
First Line	:	2406 WILDWIND RD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5503
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2406 WILDWIND RD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88007-5503
Country	:	US
Telephone Number	:	800-831-5105
Fax Number	:

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

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	01/24/2024

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