Healthcare Provider Details

I. General information

NPI: 1720172117
Provider Name (Legal Business Name): CORINA I. PROCELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CORINA PROCELL MD

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 WYOMING BLVD NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6600
  • Fax:
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number97126
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR0060934
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: