Provider Demographics
NPI:1730816083
Name:KNEISLEY, MARK ALLEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:KNEISLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 875
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:NM
Mailing Address - Zip Code:87552-9515
Mailing Address - Country:US
Mailing Address - Phone:505-470-0244
Mailing Address - Fax:
Practice Address - Street 1:#3 ROUGEMONT LN
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:NM
Practice Address - Zip Code:87552
Practice Address - Country:US
Practice Address - Phone:505-470-0244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-83310163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency