Healthcare Provider Details

I. General information

NPI: 1689947038
Provider Name (Legal Business Name): JOANNA A.S. BRIGHTWATER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 SAN MATEO BLVD NE STE 104
ALBUQUERQUE NM
87108-1382
US

IV. Provider business mailing address

303 SAN MATEO BLVD NE STE 104
ALBUQUERQUE NM
87108-1382
US

V. Phone/Fax

Practice location:
  • Phone: 505-808-2870
  • Fax:
Mailing address:
  • Phone: 505-808-2870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP02152
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN77315
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP-02152
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP-02152
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: