Provider Demographics
NPI:1073272357
Name:MEJIA, IRIDIANA
Entity type:Individual
Prefix:
First Name:IRIDIANA
Middle Name:
Last Name:MEJIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 ALAMO AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3225
Mailing Address - Country:US
Mailing Address - Phone:505-364-2122
Mailing Address - Fax:505-272-7026
Practice Address - Street 1:2350 ALAMO AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3225
Practice Address - Country:US
Practice Address - Phone:505-364-2122
Practice Address - Fax:505-272-7026
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMG-1077172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker