Healthcare Provider Details

I. General information

NPI: 1417584897
Provider Name (Legal Business Name): KACIE LEANNA FISHER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 12TH ST STE 7
ALAMOSA CO
81101-3709
US

IV. Provider business mailing address

719 SAN MATEO BLVD NE
ALBUQUERQUE NM
87108-1434
US

V. Phone/Fax

Practice location:
  • Phone: 719-589-4906
  • Fax: 719-589-3034
Mailing address:
  • Phone: 505-485-0464
  • Fax: 505-266-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number58949
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberC-APN.0001928-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: