Healthcare Provider Details

I. General information

NPI: 1316439920
Provider Name (Legal Business Name): DEANN NIETO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001B EL CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105
US

IV. Provider business mailing address

2001B EL CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4556
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5786
  • Fax:
Mailing address:
  • Phone: 505-272-5786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: