Provider Demographics
NPI:1215784038
Name:LAVALLE, JIMENA
Entity type:Individual
Prefix:
First Name:JIMENA
Middle Name:
Last Name:LAVALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 N ABILENE PL
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-4813
Mailing Address - Country:US
Mailing Address - Phone:575-607-7608
Mailing Address - Fax:
Practice Address - Street 1:1409 N ABILENE PL
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-4813
Practice Address - Country:US
Practice Address - Phone:575-607-7608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
NM68082163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife