Healthcare Provider Details

I. General information

NPI: 1639062383
Provider Name (Legal Business Name): ALEXANDRA STAUTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEX STAUTER

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 COORS BYP NW STE E1
ALBUQUERQUE NM
87114-4055
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

V. Phone/Fax

Practice location:
  • Phone: 505-677-0988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2026-0610
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: