Healthcare Provider Details

I. General information

NPI: 1750936522
Provider Name (Legal Business Name): JESSICA LUJAN APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 W PRAIRIE AVE
COEUR D ALENE ID
83815-8780
US

IV. Provider business mailing address

303 PASEO DE PERALTA
SANTA FE NM
87501-1860
US

V. Phone/Fax

Practice location:
  • Phone: 208-209-0288
  • Fax: 208-209-0289
Mailing address:
  • Phone: 505-988-2449
  • Fax: 505-819-0588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57250
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71672
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: