Healthcare Provider Details

I. General information

NPI: 1629701776
Provider Name (Legal Business Name): KELLY OBRIEN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2129 OSUNA RD NE
ALBUQUERQUE NM
87113-1002
US

IV. Provider business mailing address

6329 LOFTUS AVE NE
ALBUQUERQUE NM
87109-2717
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-2468
  • Fax:
Mailing address:
  • Phone: 505-720-9564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number68843
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: