Provider Demographics
NPI:1376645598
Name:GWALTNEY, ROSALIE MARIE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:MARIE
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:575-396-1454
Practice Address - Street 1:1600 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2830
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:575-396-1454
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044788RN207L00000X
NMCRNA00756207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44235097Medicaid
NM44235097Medicaid