Healthcare Provider Details

I. General information

NPI: 1053929265
Provider Name (Legal Business Name): MRS. CHELSEA DIANE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHELSEA DIANE CANTRALL

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

IV. Provider business mailing address

12115 LA VISTA GRANDE DR NE
ALBUQUERQUE NM
87111-6708
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-0061
  • Fax: 505-237-0068
Mailing address:
  • Phone: 505-908-1354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-11505
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: