Healthcare Provider Details

I. General information

NPI: 1689974701
Provider Name (Legal Business Name): ANGELA BAUM LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-3300
US

IV. Provider business mailing address

96 SANDIA MOUNTAIN RANCH DR
TIJERAS NM
87059-7366
US

V. Phone/Fax

Practice location:
  • Phone: 505-507-0430
  • Fax:
Mailing address:
  • Phone: 505-507-0430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5769
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: