Healthcare Provider Details

I. General information

NPI: 1578927695
Provider Name (Legal Business Name): MRS. BRIANNE ERIN WARD-HERSEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10804 MARBLE STONE DR NW
ALBUQUERQUE NM
87114-2024
US

IV. Provider business mailing address

10804 MARBLE STONE DR NW
ALBUQUERQUE NM
87114-2024
US

V. Phone/Fax

Practice location:
  • Phone: 505-415-2423
  • Fax:
Mailing address:
  • Phone: 505-415-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number506826004
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: