Healthcare Provider Details

I. General information

NPI: 1356717680
Provider Name (Legal Business Name): CATHERINE MCQUEEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JUAN TABO BLVD NE SUITE 140
ALBUQUERQUE NM
87111-2681
US

IV. Provider business mailing address

4425 JUAN TABO BLVD NE SUITE 140
ALBUQUERQUE NM
87111-2681
US

V. Phone/Fax

Practice location:
  • Phone: 505-332-8070
  • Fax: 505-275-6678
Mailing address:
  • Phone: 505-332-8070
  • Fax: 505-275-6678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-1024
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: