Healthcare Provider Details

I. General information

NPI: 1417380700
Provider Name (Legal Business Name): FALLON LAWS GRAVELY RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2013
Last Update Date: 04/27/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SAN PEDRO DR NE STE 205J
ALBUQUERQUE NM
87110-6749
US

IV. Provider business mailing address

PO BOX 571
ESTANCIA NM
87016-0571
US

V. Phone/Fax

Practice location:
  • Phone: 505-658-1561
  • Fax: 505-445-0774
Mailing address:
  • Phone: 505-658-1549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-83568
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03186
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP03186
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-03186
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: