Healthcare Provider Details

I. General information

NPI: 1033502596
Provider Name (Legal Business Name): MRS. SUSAN NANCY GOEKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MADEIRA DRIVE S.E.
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

123 MADEIRA DR SE
ALBUQUERQUE NM
87108-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-1538
  • Fax:
Mailing address:
  • Phone: 505-262-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR29441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: