Healthcare Provider Details

I. General information

NPI: 1548729296
Provider Name (Legal Business Name): LEOTA MERLE JENTZEN APRN-CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6020 SILVER LEAF TRL NE
ALBUQUERQUE NM
87111-8095
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 806-640-2790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55391
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: