Healthcare Provider Details

I. General information

NPI: 1972707362
Provider Name (Legal Business Name): ELIZABETH RUTH GARDNER CCNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

6316 SUMAC DR NW
ALBUQUERQUE NM
87120-2577
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-2725
  • Fax:
Mailing address:
  • Phone: 505-899-1344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR51515
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: