Healthcare Provider Details

I. General information

NPI: 1275367096
Provider Name (Legal Business Name): MARITZA RUNK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 3452
ALBUQUERQUE NM
87190-3452
US

IV. Provider business mailing address

PO BOX 3452
ALBUQUERQUE NM
87190-3452
US

V. Phone/Fax

Practice location:
  • Phone: 786-853-4584
  • Fax:
Mailing address:
  • Phone: 786-853-4584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: