Healthcare Provider Details

I. General information

NPI: 1932234085
Provider Name (Legal Business Name): CHERYL L KIRK-MCMULLEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12404 LOS ARBOLES AVE NE
ALBUQUERQUE NM
87112-2076
US

IV. Provider business mailing address

12404 LOS ARBOLES AVE NE
ALBUQUERQUE NM
87112-2076
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-0949
  • Fax: 505-323-8362
Mailing address:
  • Phone: 505-350-0949
  • Fax: 505-323-8362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number1873
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: