Provider Demographics
NPI:1972925956
Name:FALLERT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FALLERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MONTEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:STE A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:826 ANTHONY DR.
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:575-201-5135
Practice Address - Fax:575-201-5131
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM57084726Medicaid
NM72545Medicaid