Provider Demographics
NPI:1669246443
Name:MARRUJO-MOCTEZUMA, TENNILLE ALEXA (RN)
Entity type:Individual
Prefix:
First Name:TENNILLE
Middle Name:ALEXA
Last Name:MARRUJO-MOCTEZUMA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 SALADO CREEK ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-5072
Mailing Address - Country:US
Mailing Address - Phone:575-644-9254
Mailing Address - Fax:
Practice Address - Street 1:4733 SALADO CREEK ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-5072
Practice Address - Country:US
Practice Address - Phone:575-644-9254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81131363LP0808X
NMR63735163WC1600X, 163WP0807X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult