Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 3073 | NM |
NPI | 1003233172 |
---|---|
Provider Name | Annette Angela Baca |
First Address | Belen, NM 87002-3720 |
Second Address | Belen, NM 87002-3720 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2014 |
Last Update Date | 26/03/2014 |