Healthcare Provider Details

I. General information

NPI: 1639977275
Provider Name (Legal Business Name): ELIZABETH DIANE CHAVEZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10601 4TH ST NW
ALBUQUERQUE NM
87114-2407
US

IV. Provider business mailing address

10601 4TH ST NW
ALBUQUERQUE NM
87114-2407
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-3000
  • Fax: 505-828-3002
Mailing address:
  • Phone: 505-828-3000
  • Fax: 505-828-3002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55655
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: