Healthcare Provider Details

I. General information

NPI: 1316742760
Provider Name (Legal Business Name): FAITH OMAMOGHO IGBERAESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4318
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-6200
  • Fax:
Mailing address:
  • Phone: 505-727-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN.0182083
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPN.1000499-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberAPN.1000499-NP
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number83157
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: