MEDICARE: MIND AND BODY MEDICAL AND RECOVERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1689478505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND AND BODY MEDICAL AND RECOVERY

Provider Business Mailing Address
First Line	:	2900 LOUISIANA BLVD NE STE A2
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3550
Country	:	US
Telephone Number	:	505-999-0470
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 LOUISIANA BLVD NE STE A2
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3550
Country	:	US
Telephone Number	:	505-999-0470
Fax Number	:

Authorized Official
Title or Position	:	PSYCHIATRIC MENTAL HEALTH NP
Name	:	NICOLE MESTAS
Credential	:	PMHNP-BC
Telephone Number	:	505-999-0470

Provider Enumeration Date	:	04/01/2025
Last Update Date	:	04/01/2025

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