Healthcare Provider Details

I. General information

NPI: 1407342652
Provider Name (Legal Business Name): JODI NOTAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 RIDGECREST DR SE
ALBUQUERQUE NM
87108-5152
US

IV. Provider business mailing address

2305 RENARD PL SE STE 20087107
ALBUQUERQUE NM
87106-4258
US

V. Phone/Fax

Practice location:
  • Phone: 505-938-1060
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: