Provider Demographics
NPI:1407144884
Name:MUNOZ, ROSELIE L (MA)
Entity Type:Individual
Prefix:MRS
First Name:ROSELIE
Middle Name:L
Last Name:MUNOZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:ROSELIE
Other - Middle Name:L
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:880 ANTHONY DR
Practice Address - Street 2:SUITE 12
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-9346
Practice Address - Country:US
Practice Address - Phone:575-201-5134
Practice Address - Fax:575-201-5108
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid