Healthcare Provider Details

I. General information

NPI: 1770618399
Provider Name (Legal Business Name): ANN ELAINE BURCHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

IV. Provider business mailing address

11621 SAN ANTONIO DR NE
ALBUQUERQUE NM
87122-2437
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7047
  • Fax:
Mailing address:
  • Phone: 505-856-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberR19033
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: