Provider Demographics
NPI:1497770648
Name:ALCALA MOSS, ADRIANE AMANA (PMHNP)
Entity Type:Individual
Prefix:
First Name:ADRIANE
Middle Name:AMANA
Last Name:ALCALA MOSS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-8700
Mailing Address - Country:US
Mailing Address - Phone:575-446-5310
Mailing Address - Fax:575-446-5319
Practice Address - Street 1:4585 SW 185TH AVE
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97007
Practice Address - Country:US
Practice Address - Phone:503-591-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450121NP PMHNP-PP363LP0808X
NMCNP-03213363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR277800Medicaid
NMCNP-03213OtherNM LICENSE