Provider Demographics
NPI:1952037269
Name:REYES, XYTLALLI JESENIA
Entity Type:Individual
Prefix:
First Name:XYTLALLI
Middle Name:JESENIA
Last Name:REYES
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 1:4790 NORTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-9572
Mailing Address - Country:US
Mailing Address - Phone:575-635-3474
Mailing Address - Fax:
Practice Address - Street 1:1320 S SOLANO DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3758
Practice Address - Country:US
Practice Address - Phone:575-522-4004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10215562800Medicaid