Healthcare Provider Details

I. General information

NPI: 1578431938
Provider Name (Legal Business Name): SOPHEAP LY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSTITUTION AVE NE
ALBUQUERQUE NM
87110-7613
US

IV. Provider business mailing address

6 ROAD 6211
KIRTLAND NM
87417-9706
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-2122
  • Fax:
Mailing address:
  • Phone: 505-358-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF10250869
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: