Provider Demographics
NPI:1760961908
Name:HALCYON HEALTH OF THE SOUTHWEST, LLC
Entity Type:Organization
Organization Name:HALCYON HEALTH OF THE SOUTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:931-636-6648
Mailing Address - Street 1:1355 CALIFORNIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-4187
Mailing Address - Country:US
Mailing Address - Phone:575-523-8951
Mailing Address - Fax:575-366-8011
Practice Address - Street 1:1355 CALIFORNIA AVE STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:575-523-8951
Practice Address - Fax:575-366-8011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02392363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64634876Medicaid