Provider Demographics
NPI:1134424880
Name:ABEYTA VIGIL, CHARLENE YVETTE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:YVETTE
Last Name:ABEYTA VIGIL
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:PO BOX 6952
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-8094
Mailing Address - Country:US
Mailing Address - Phone:575-758-5857
Mailing Address - Fax:575-758-2832
Practice Address - Street 1:413 SIPAPU ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6489
Practice Address - Country:US
Practice Address - Phone:575-758-5857
Practice Address - Fax:575-758-2832
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist