Healthcare Provider Details

I. General information

NPI: 1699161216
Provider Name (Legal Business Name): TURQUOISE MESA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2015
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 CENTRAL AVE NW SUITE K-2
ALBUQUERQUE NM
87105-1630
US

IV. Provider business mailing address

4201 CENTRAL AVE NW SUITE K-2
ALBUQUERQUE NM
87105-1630
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-7250
  • Fax: 505-554-2313
Mailing address:
  • Phone: 505-503-7250
  • Fax: 505-554-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP02306
License Number StateNM

VIII. Authorized Official

Name: JULIANNE AUSTIN
Title or Position: MEMBER/NURSE PRACTITIONER
Credential: CNP
Phone: 352-250-5350