Healthcare Provider Details

I. General information

NPI: 1548513716
Provider Name (Legal Business Name): LISA MARIE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M TAYLOR CNP

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 JOURNAL CENTER BLVD NE FL 2
ALBUQUERQUE NM
87109-5900
US

IV. Provider business mailing address

PO BOX 26028 CLINICIAN SERVICES
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7455
  • Fax: 505-262-3955
Mailing address:
  • Phone: 505-262-7963
  • Fax: 505-232-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP02168
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: