Healthcare Provider Details

I. General information

NPI: 1740096155
Provider Name (Legal Business Name): SHONTELLE ANTOINETTE LUJAN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 BROADBENT PKWY NE STE A
ALBUQUERQUE NM
87107-1623
US

IV. Provider business mailing address

2525 TINGLEY DR SW APT 305
ALBUQUERQUE NM
87104-1655
US

V. Phone/Fax

Practice location:
  • Phone: 800-237-6257
  • Fax:
Mailing address:
  • Phone: 505-819-7439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number75475
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: