Healthcare Provider Details

I. General information

NPI: 1275978785
Provider Name (Legal Business Name): THERESA E NUSSBAUMER ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone: 505-823-8870
  • Fax: 505-823-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP-02139
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS-00237
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: