Healthcare Provider Details

I. General information

NPI: 1457187114
Provider Name (Legal Business Name): STEPHANIE MICHEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

1617 EL PATIO PL SW
ALBUQUERQUE NM
87105-4860
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2571
  • Fax:
Mailing address:
  • Phone: 505-227-0710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number24345219
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: