Healthcare Provider Details

I. General information

NPI: 1619013869
Provider Name (Legal Business Name): SUSAN J SMITH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 MENAUL BLVD NE CVS MINUTE CLINIC
ALBUQUERQUE NM
87112-2217
US

IV. Provider business mailing address

9640 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2217
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-4167
  • Fax:
Mailing address:
  • Phone: 505-294-4167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR30405
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR30405
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: