Healthcare Provider Details

I. General information

NPI: 1083593388
Provider Name (Legal Business Name): MODERN EDGE FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 LOUISIANA BLVD NE STE 200
ALBUQUERQUE NM
87110-4400
US

IV. Provider business mailing address

2440 LOUISIANA BLVD NE STE 200
ALBUQUERQUE NM
87110-4400
US

V. Phone/Fax

Practice location:
  • Phone: 505-370-9195
  • Fax: 505-212-4007
Mailing address:
  • Phone: 505-370-9195
  • Fax: 505-212-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. SONYA WALSH
Title or Position: OWNER/NURSE PRACTITIONER
Credential: CNP
Phone: 505-370-9195