Healthcare Provider Details

I. General information

NPI: 1669174314
Provider Name (Legal Business Name): COURTNEY DIANNE IERONIMO DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 RIO GRANDE BLVD NW STE A
ALBUQUERQUE NM
87104-3233
US

IV. Provider business mailing address

441 ASH ST NE
ALBUQUERQUE NM
87106-4557
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-0071
  • Fax:
Mailing address:
  • Phone: 505-289-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAOM-2023-0013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: