Provider Demographics
NPI:1982115879
Name:AUGUSTINE, XENA (DOM)
Entity Type:Individual
Prefix:
First Name:XENA
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WILLOW BACK RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1484
Mailing Address - Country:US
Mailing Address - Phone:505-204-2633
Mailing Address - Fax:
Practice Address - Street 1:1807 2ND ST STE 45-3
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3499
Practice Address - Country:US
Practice Address - Phone:505-204-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1209171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty