Healthcare Provider Details

I. General information

NPI: 1538140330
Provider Name (Legal Business Name): ANDREA YVONNE SUTPHIN R. N.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JOHN DANTIS RD SW
ALBUQUERQUE NM
87151-0100
US

IV. Provider business mailing address

908 BLACKBIRD DR SW
ALBUQUERQUE NM
87121-9013
US

V. Phone/Fax

Practice location:
  • Phone: 505-839-8837
  • Fax: 505-839-8989
Mailing address:
  • Phone: 505-242-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberR14245
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: