Healthcare Provider Details

I. General information

NPI: 1407586621
Provider Name (Legal Business Name): CRYSTAL DENISE MCCLAIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2022
Last Update Date: 03/01/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8417 WASHINGTON PL NE STE A
ALBUQUERQUE NM
87113-1720
US

IV. Provider business mailing address

8417 WASHINGTON PL NE STE A
ALBUQUERQUE NM
87113-1720
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-9453
  • Fax: 949-862-5382
Mailing address:
  • Phone: 505-273-9453
  • Fax: 949-862-5382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number68303
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: