Provider Demographics
NPI:1093175523
Name:PORTILLO, DOROTHY M (FNP-C)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:M
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DOROTHY
Other - Middle Name:MARTINEZ
Other - Last Name:PORTILLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:999 W AMADOR AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2739
Mailing Address - Country:US
Mailing Address - Phone:575-527-5482
Mailing Address - Fax:575-525-3542
Practice Address - Street 1:999 W AMADOR AVE STE D
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2739
Practice Address - Country:US
Practice Address - Phone:575-527-5482
Practice Address - Fax:575-525-3542
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02857363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily