Healthcare Provider Details

I. General information

NPI: 1053075978
Provider Name (Legal Business Name): KELLY CONKLIN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 4TH ST NW
ALBUQUERQUE NM
87107-2510
US

IV. Provider business mailing address

10415 TALL ROCK CT NW
ALBUQUERQUE NM
87114-6078
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-4493
  • Fax:
Mailing address:
  • Phone: 505-620-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65689
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: