Healthcare Provider Details

I. General information

NPI: 1669065462
Provider Name (Legal Business Name): JENNIFER LEE CHURCHILL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7808 CALLE DE PLATA NE
ALBUQUERQUE NM
87109-4863
US

IV. Provider business mailing address

7808 CALLE DE PLATA NE
ALBUQUERQUE NM
87109-4863
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-6976
  • Fax:
Mailing address:
  • Phone: 505-321-6976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number62684
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: