Provider Demographics
NPI:1629803705
Name:QUEZADA MICHEL, DEVORA (CHW)
Entity type:Individual
Prefix:
First Name:DEVORA
Middle Name:
Last Name:QUEZADA MICHEL
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 SAN PEDRO DR NE STE 108
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6744
Mailing Address - Country:US
Mailing Address - Phone:505-908-5702
Mailing Address - Fax:505-273-3115
Practice Address - Street 1:1330 SAN PEDRO DR NE STE 108
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6744
Practice Address - Country:US
Practice Address - Phone:505-908-5702
Practice Address - Fax:505-273-3115
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMS1-1400172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker