Provider Demographics
NPI:1376536854
Name:GUTIERREZ, EDNA GAIL (CNP)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:GAIL
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:EDNA
Other - Middle Name:GAIL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0299
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:575-359-6827
Practice Address - Street 1:121 N. MAIN
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:NM
Practice Address - Zip Code:88124
Practice Address - Country:US
Practice Address - Phone:575-253-4373
Practice Address - Fax:575-253-4575
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR30396363LF0000X
NMCNP00610363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
R13385Medicare UPIN
345508704Medicare ID - Type Unspecified