Healthcare Provider Details

I. General information

NPI: 1255843710
Provider Name (Legal Business Name): BERNADETTE PEREA-ZAMORA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. BERNADETTE M PEREA-ZAMORA

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

IV. Provider business mailing address

601 DR MARTIN LUTHER KING JR AVE NE
ALBUQUERQUE NM
87102-3619
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-3458
  • Fax: 505-508-3458
Mailing address:
  • Phone: 505-550-7362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03412
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR46548
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: