Provider Demographics
NPI:1023580073
Name:MEDRANO, LETICIA (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6471
Mailing Address - Country:US
Mailing Address - Phone:575-625-1292
Mailing Address - Fax:575-624-4836
Practice Address - Street 1:115 E 23RD ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6471
Practice Address - Country:US
Practice Address - Phone:575-625-1292
Practice Address - Fax:575-624-4836
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily