Basic Information
| Provider Information | |||||||||
| NPI: | 1780137117 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACZALA | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEGNER | ||||||||
| OtherFirstName: | LINDA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST STE 249 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752575884 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST STE 249 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5752575884 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2016 | ||||||||
| LastUpdateDate: | 08/02/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | RN-83332 | NM | Y | Nursing Service Providers | Registered Nurse | School |
No ID Information.