Provider Demographics
NPI:1568852440
Name:RELIFORD, MARJORIE NICOLE (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:NICOLE
Last Name:RELIFORD
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:RELIFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:4305 N MESA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1123
Mailing Address - Country:US
Mailing Address - Phone:915-532-2477
Mailing Address - Fax:915-532-2470
Practice Address - Street 1:4305 N MESA ST
Practice Address - Street 2:SUITE A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1123
Practice Address - Country:US
Practice Address - Phone:915-532-2477
Practice Address - Fax:915-532-2470
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128109363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP128109OtherLICENSE
TX0346398601Medicaid
TX411046YQQPMedicare PIN