Healthcare Provider Details

I. General information

NPI: 1477105088
Provider Name (Legal Business Name): NICOLE CHRISTINE PACHECO CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2019
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3821 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4679
US

IV. Provider business mailing address

3821 MASTHEAD ST NE
ALBUQUERQUE NM
87109-4679
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-7400
  • Fax:
Mailing address:
  • Phone: 505-998-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number56792
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: