Healthcare Provider Details

I. General information

NPI: 1003361841
Provider Name (Legal Business Name): DENA FAHLQUIST AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CEDAR ST SE
ALBUQUERQUE NM
87106-3927
US

IV. Provider business mailing address

415 CEDAR ST SE
ALBUQUERQUE NM
87106-3927
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-5810
  • Fax: 505-842-5816
Mailing address:
  • Phone: 505-842-5810
  • Fax: 505-842-5816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number6062
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: