Provider Demographics
NPI:1629394887
Name:MILLS, JONELL (LMT)
Entity Type:Individual
Prefix:
First Name:JONELL
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2559
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-2559
Mailing Address - Country:US
Mailing Address - Phone:575-751-7594
Mailing Address - Fax:
Practice Address - Street 1:192 MIRANDA CANYON RD
Practice Address - Street 2:
Practice Address - City:RANCHOS DE TAOS
Practice Address - State:NM
Practice Address - Zip Code:87557-2559
Practice Address - Country:US
Practice Address - Phone:575-751-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1938225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist