Provider Demographics
NPI:1073210969
Name:TREJO-WINN, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TREJO-WINN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DOVE RD
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-5906
Mailing Address - Country:US
Mailing Address - Phone:505-771-6759
Mailing Address - Fax:
Practice Address - Street 1:2 DOVE RD
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-5906
Practice Address - Country:US
Practice Address - Phone:505-771-6759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1793378171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM054762526OtherDL