Healthcare Provider Details

I. General information

NPI: 1831563287
Provider Name (Legal Business Name): ALEXANDRA NUTIMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 KAAS TRAIL CT NE
ALBUQUERQUE NM
87111-7114
US

IV. Provider business mailing address

10200 GREEN RIVER PL NW
ALBUQUERQUE NM
87114-3965
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-6163
  • Fax:
Mailing address:
  • Phone: 623-533-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: