Healthcare Provider Details

I. General information

NPI: 1154208312
Provider Name (Legal Business Name): MICHELLLE VENEZIA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

IV. Provider business mailing address

1 SAGEBRUSH ST SW
ALBUQUERQUE NM
87105-3942
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-3200
  • Fax: 505-869-4893
Mailing address:
  • Phone: 505-869-4893
  • Fax: 505-869-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberG-1852
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: