Healthcare Provider Details

I. General information

NPI: 1700231131
Provider Name (Legal Business Name): NICOLE ZYLSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 ZUNI RD SE
ALBUQUERQUE NM
87108-2926
US

IV. Provider business mailing address

5608 ZUNI RD SE
ALBUQUERQUE NM
87108-2926
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-6520
  • Fax:
Mailing address:
  • Phone: 505-262-6520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09464
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: