Healthcare Provider Details

I. General information

NPI: 1578740262
Provider Name (Legal Business Name): NICOLE MARIE PATTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 ELK HORN DR NE
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

6325 ELK HORN DR NE
ALBUQUERQUE NM
87111-7220
US

V. Phone/Fax

Practice location:
  • Phone: 505-681-7874
  • Fax:
Mailing address:
  • Phone: 505-681-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: