Healthcare Provider Details

I. General information

NPI: 1215260328
Provider Name (Legal Business Name): JAMIE STAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 ALAMO AVE SE
ALBUQUERQUE NM
87106-3204
US

IV. Provider business mailing address

2450 ALAMO AVE SE
ALBUQUERQUE NM
87106-3204
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-2421
  • Fax: 505-925-2411
Mailing address:
  • Phone: 505-925-2421
  • Fax: 505-925-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberR65828
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: