Healthcare Provider Details

I. General information

NPI: 1740395813
Provider Name (Legal Business Name): CAROL NELSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL BOETTGER

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5046
US

IV. Provider business mailing address

1325 WYOMING BLVD NE
ALBUQUERQUE NM
87112-5046
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-5300
  • Fax:
Mailing address:
  • Phone: 505-291-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD2009-0640
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD2009-0640
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: