Provider Demographics
NPI:1003812553
Name:MACKLIN, LYDIA (CNP)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:CARRENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:855 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:575-882-5706
Practice Address - Fax:575-882-2909
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR37028163W00000X
NMCNP00803363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM343502805OtherMEDICARE
NM98827529Medicaid