Healthcare Provider Details

I. General information

NPI: 1679969497
Provider Name (Legal Business Name): AVA ANN BOSWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8204 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-1737
US

IV. Provider business mailing address

8204 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-1737
US

V. Phone/Fax

Practice location:
  • Phone: 505-582-2180
  • Fax: 505-639-4145
Mailing address:
  • Phone: 505-480-5156
  • Fax: 505-639-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME151214
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD2017-0791
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2017-0791
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: