Healthcare Provider Details

I. General information

NPI: 1043240229
Provider Name (Legal Business Name): STEPHANIE ANNETTE MOYA MD, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

865 SILVER AVE SW
ALBUQUERQUE NM
87102-3020
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5455
Mailing address:
  • Phone: 480-703-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number933782
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: