Provider Demographics
NPI:1154739167
Name:VALLEJOS, ANNIE (CNP)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:VALLEJOS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:MEREDITH
Other - Last Name:WALNECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5770
Mailing Address - Fax:
Practice Address - Street 1:3777 NM HIGHWAY 528 NW
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7650
Practice Address - Country:US
Practice Address - Phone:505-404-2590
Practice Address - Fax:505-404-2591
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02474363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83237208Medicaid