Healthcare Provider Details

I. General information

NPI: 1841956653
Provider Name (Legal Business Name): JENNIFER VANESSA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CARMEL AVE NE STE 601
ALBUQUERQUE NM
87122-3125
US

IV. Provider business mailing address

7016 SILVER MOUNTAIN LOOP NE
RIO RANCHO NM
87144-6726
US

V. Phone/Fax

Practice location:
  • Phone: 505-677-8842
  • Fax: 505-501-7451
Mailing address:
  • Phone: 505-206-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR56398
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: