Healthcare Provider Details

I. General information

NPI: 1841465788
Provider Name (Legal Business Name): MRS. ANDREA M MULFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87112-4160
US

IV. Provider business mailing address

1524 EUBANK BLVD NE STE 1
ALBUQUERQUE NM
87112-4160
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-2508
  • Fax: 505-292-2509
Mailing address:
  • Phone: 505-292-2508
  • Fax: 505-292-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0616920001
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: