Healthcare Provider Details

I. General information

NPI: 1306286638
Provider Name (Legal Business Name): MS. PENNY LYNN DAHLSON-LUEDTKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 YALE BLVD SE BLDG F
ALBUQUERQUE NM
87106-4228
US

IV. Provider business mailing address

2301 YALE BLVD SE BLDG F
ALBUQUERQUE NM
87106-4228
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-7033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: