Healthcare Provider Details

I. General information

NPI: 1134355407
Provider Name (Legal Business Name): PAMELA ANN CORNISH DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 MANZANO ST NE
ALBUQUERQUE NM
87108-1309
US

IV. Provider business mailing address

312 MANZANO ST NE
ALBUQUERQUE NM
87108-1309
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-5277
  • Fax: 505-266-5289
Mailing address:
  • Phone: 505-266-5277
  • Fax: 505-266-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number352
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: