Healthcare Provider Details

I. General information

NPI: 1285285395
Provider Name (Legal Business Name): CRYSTAL CHICK AGPC-NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax: 505-246-0684
Mailing address:
  • Phone: 505-842-8171
  • Fax: 505-246-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0995019-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number63441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: