1700696572 NPI number — MRS. PAIGE LAVONNE ERICKSON RN

Table of content: MRS. PAIGE LAVONNE ERICKSON RN (NPI 1700696572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700696572 NPI number — MRS. PAIGE LAVONNE ERICKSON RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
PAIGE
Provider Middle Name:
LAVONNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700696572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVIS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88102-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-769-4490
Provider Business Mailing Address Fax Number:
575-769-4430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-5932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-769-4490
Provider Business Practice Location Address Fax Number:
575-769-4430
Provider Enumeration Date:
01/13/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  78979 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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