Provider Demographics
NPI:1760586093
Name:KIZIAH, DARLA (CNP)
Entity Type:Individual
Prefix:
First Name:DARLA
Middle Name:
Last Name:KIZIAH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W BROADWAY ST
Mailing Address - Street 2:STE 1
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-6068
Mailing Address - Country:US
Mailing Address - Phone:575-393-3168
Mailing Address - Fax:575-397-3664
Practice Address - Street 1:920 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-5529
Practice Address - Country:US
Practice Address - Phone:575-393-3168
Practice Address - Fax:575-397-3664
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR43640363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04070321Medicaid
NMNM006E93OtherBCBS
NM04070321Medicaid