Healthcare Provider Details

I. General information

NPI: 1689486003
Provider Name (Legal Business Name): NICOLE DANIELLE MANSOUR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 08/13/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 ACADEMY RD NE BLDG 2 SUITE 104
ALBUQUERQUE NM
87109-3379
US

IV. Provider business mailing address

2318 GARDEN RD NE
RIO RANCHO NM
87124-2431
US

V. Phone/Fax

Practice location:
  • Phone: 505-730-5020
  • Fax:
Mailing address:
  • Phone: 505-459-4602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number82459
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: