Healthcare Provider Details

I. General information

NPI: 1689097891
Provider Name (Legal Business Name): BERNADETTE PORTILLO MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2014
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE MAIL CODE 122-H
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-265-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR63706
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberR63706
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: