Healthcare Provider Details

I. General information

NPI: 1487887782
Provider Name (Legal Business Name): CAROL D. LARUE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 09/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 3RD ST
ALBUQUERQUE NM
87125
US

IV. Provider business mailing address

12013RD ST ST MARTIN'S HOSPITALITY CENTER
ALBUQUERUQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-764-8231
  • Fax: 505-248-1351
Mailing address:
  • Phone: 505-764-8231
  • Fax: 505-248-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR20858
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: