Healthcare Provider Details

I. General information

NPI: 1568993079
Provider Name (Legal Business Name): MRS. KATHY MARIE MCINTYRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 03/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 TAYLOR RANCH RD NW SUITE C8
ALBUQUERQUE NM
87120-2963
US

IV. Provider business mailing address

6911 TAYLOR RANCH RD NW SUITE C8
ALBUQUERQUE NM
87120-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-2674
  • Fax:
Mailing address:
  • Phone: 505-433-2674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: