Healthcare Provider Details

I. General information

NPI: 1730169699
Provider Name (Legal Business Name): JUDITH M VERGARA-BLAKE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH M HARDING CNP

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WALTER ST SE
ALBUQUERQUE NM
87102-4658
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-1393
  • Fax: 505-272-2177
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberR51480
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: