Healthcare Provider Details

I. General information

NPI: 1992129209
Provider Name (Legal Business Name): ANDREA CETERA-JINES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 GRANITE AVE NW
ALBUQUERQUE NM
87102-1851
US

IV. Provider business mailing address

1109 GRANITE AVE NW
ALBUQUERQUE NM
87102-1851
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-5292
  • Fax: 505-214-5386
Mailing address:
  • Phone: 505-508-5292
  • Fax: 505-214-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberFA0083460
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: