Healthcare Provider Details

I. General information

NPI: 1275867517
Provider Name (Legal Business Name): JENNIFER ANN PROCTOR CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ANN KOCH

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date: 05/28/2018
Reactivation Date: 06/05/2018

III. Provider practice location address

7801 ACADEMY RD NE # 2
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2700
  • Fax:
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-03598
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: