Provider Demographics
NPI:1487710216
Name:WILSON MCELYEA, DIANNE C (CNP)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:C
Last Name:WILSON MCELYEA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:C
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:5528 KALAHARI LN
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7252
Mailing Address - Country:US
Mailing Address - Phone:480-280-5400
Mailing Address - Fax:505-532-8910
Practice Address - Street 1:2701 MISSOURI AVE
Practice Address - Street 2:STE A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5091
Practice Address - Country:US
Practice Address - Phone:575-522-7880
Practice Address - Fax:575-522-7226
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR34632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR34632OtherLICENSE