Healthcare Provider Details

I. General information

NPI: 1023206976
Provider Name (Legal Business Name): JILL MARIE STAPE I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILL MARIE STAPE D.O.M.

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9809 CANDELARIA RD NE SUITE 3
ALBUQUERQUE NM
87112-1458
US

IV. Provider business mailing address

9809 CANDELARIA RD NE SUITE 3
ALBUQUERQUE NM
87112-1458
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-4325
  • Fax:
Mailing address:
  • Phone: 505-298-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number636
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: