Healthcare Provider Details

I. General information

NPI: 1144487307
Provider Name (Legal Business Name): JESSICA R PROCHNOW RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

PO BOX 56785
ALBUQUERQUE NM
87187-6785
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number71020
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: