Healthcare Provider Details

I. General information

NPI: 1366933384
Provider Name (Legal Business Name): MRS. SARA MILLER COBB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

6201 ZALTANA RD NW
ALBUQUERQUE NM
87120-5596
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2479
  • Fax:
Mailing address:
  • Phone: 802-233-9239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: