Healthcare Provider Details

I. General information

NPI: 1891268702
Provider Name (Legal Business Name): MISS JANEIL F NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS JANEIL F RUNYAN

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

IV. Provider business mailing address

1910 ALVARADO DR NE
ALBUQUERQUE NM
87110-5104
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5295
  • Fax:
Mailing address:
  • Phone: 505-219-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: