Provider Demographics
NPI:1598353906
Name:MACIAS, MIRABELLA
Entity Type:Individual
Prefix:
First Name:MIRABELLA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 BOLDT ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3876
Mailing Address - Country:US
Mailing Address - Phone:575-640-2758
Mailing Address - Fax:
Practice Address - Street 1:2700 BOLDT ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3876
Practice Address - Country:US
Practice Address - Phone:575-640-2758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-02
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1324133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered