Healthcare Provider Details

I. General information

NPI: 1114407251
Provider Name (Legal Business Name): ABIGAIL R SULLIVAN DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10433 MONTGOMERY PKWY NE
ALBUQUERQUE NM
87111-3831
US

IV. Provider business mailing address

604 AGUA FRIA ST
SANTA FE NM
87501-2577
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-1610
  • Fax:
Mailing address:
  • Phone: 505-303-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDOM1230
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: