Healthcare Provider Details

I. General information

NPI: 1013677350
Provider Name (Legal Business Name): LISA MICHELLE BACA-HUMMELL MSN, RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/29/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2437 CUTLER AVE NE
ALBUQUERQUE NM
87106-2507
US

IV. Provider business mailing address

2437 CUTLER AVE NE
ALBUQUERQUE NM
87106-2507
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-0311
  • Fax:
Mailing address:
  • Phone: 505-379-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number09211462
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: