Healthcare Provider Details

I. General information

NPI: 1730466715
Provider Name (Legal Business Name): FAMILY HEALTH CLINIC OF NEW MEXICO INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 4TH ST NW
ALBUQUERQUE NM
87107-2510
US

IV. Provider business mailing address

3911 4TH ST NW
ALBUQUERQUE NM
87107-2510
US

V. Phone/Fax

Practice location:
  • Phone: 505-469-0730
  • Fax:
Mailing address:
  • Phone: 505-469-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00707
License Number StateNM

VIII. Authorized Official

Name: LISA BRAZIL
Title or Position: CERTIFIED FAMILY NURSE PRACTITIONER
Credential: FNP-BC
Phone: 505-469-0730