Healthcare Provider Details

I. General information

NPI: 1154204998
Provider Name (Legal Business Name): NATHAN KUNKLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

PO BOX 23445
ALBUQUERQUE NM
87192-1445
US

V. Phone/Fax

Practice location:
  • Phone: 505-767-1115
  • Fax:
Mailing address:
  • Phone: 505-767-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2025-1185
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: