Healthcare Provider Details

I. General information

NPI: 1306570858
Provider Name (Legal Business Name): SAVANNA LEE NOEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3661
US

IV. Provider business mailing address

715 DR MARTIN LUTHER KING JR AVE NE STE 301
ALBUQUERQUE NM
87102-3668
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7096
  • Fax: 505-727-7090
Mailing address:
  • Phone: 505-727-7090
  • Fax: 505-727-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN-79111
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number69239
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: