Healthcare Provider Details

I. General information

NPI: 1417186560
Provider Name (Legal Business Name): MARIE ELIZABETH MUGAVIN PHD, FNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 05/24/2024
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 MCLEOD RD NE STE D
ALBUQUERQUE NM
87109-2467
US

IV. Provider business mailing address

PO BOX 14888
ALBUQUERQUE NM
87191-4888
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-1167
  • Fax: 505-212-0332
Mailing address:
  • Phone: 505-508-1167
  • Fax: 505-212-0332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR39817
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP00879
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: