Provider Demographics
NPI:1326807751
Name:DAVALOS, MONICA ANNETTE
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ANNETTE
Last Name:DAVALOS
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:PO BOX 807
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-0807
Mailing Address - Country:US
Mailing Address - Phone:423-490-5750
Mailing Address - Fax:
Practice Address - Street 1:2810 SUDDERTH DR STE A
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6348
Practice Address - Country:US
Practice Address - Phone:423-490-5750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPM22006174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist