Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 1479 | NM |
NPI | 1356457493 |
---|---|
Provider Name | Mary V Peebles |
First Address | Ruidoso, NM 88345-6320 |
Second Address | Ruidoso, NM 88345-6320 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2006 |
Last Update Date | 23/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
$$$$$$$$$ | (02) | NM |