Healthcare Provider Details

I. General information

NPI: 1396065074
Provider Name (Legal Business Name): ROSE WILLOW CUNNINGHAM PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 RIVERSIDE PLAZA LN NW SUITE 150
ALBUQUERQUE NM
87120-2681
US

IV. Provider business mailing address

600 CENTRAL AVE SE SUITE D
ALBUQUERQUE NM
87102-3656
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-7930
  • Fax: 505-717-2818
Mailing address:
  • Phone: 505-242-2294
  • Fax: 505-242-2917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: