Healthcare Provider Details

I. General information

NPI: 1295180438
Provider Name (Legal Business Name): ALEXANDRA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7305 RAYMOND DR NE
ALBUQUERQUE NM
87109-5423
US

IV. Provider business mailing address

7305 RAYMOND DR NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-306-4069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: