Provider Demographics
NPI:1093317679
Name:NDENECHO, MIRIAM
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:NDENECHO
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 1:6972 BLACK MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79934-2233
Mailing Address - Country:US
Mailing Address - Phone:618-900-2692
Mailing Address - Fax:
Practice Address - Street 1:1001 ENCLAVE BLVD APT 506
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-7462
Practice Address - Country:US
Practice Address - Phone:618-900-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225189163W00000X
TX1052250367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse