Healthcare Provider Details

I. General information

NPI: 1174631048
Provider Name (Legal Business Name): JUDY KAY ROSE APRN C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3820 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

IV. Provider business mailing address

3820 COMMONS AVE NE
ALBUQUERQUE NM
87109-5831
US

V. Phone/Fax

Practice location:
  • Phone: 505-923-4401
  • Fax: 505-343-1862
Mailing address:
  • Phone: 505-923-4401
  • Fax: 505-343-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01134
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: