Healthcare Provider Details

I. General information

NPI: 1831753508
Provider Name (Legal Business Name): JENNIFER LYDIA CASTRO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LYDIA CASTRO NP-C

II. Dates (important events)

Enumeration Date: 04/27/2019
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MONTANO RD NW STE A1
ALBUQUERQUE NM
87107-5200
US

IV. Provider business mailing address

PO BOX 740018
ATLANTA GA
30374-0018
US

V. Phone/Fax

Practice location:
  • Phone: 505-777-3003
  • Fax:
Mailing address:
  • Phone: 773-352-1517
  • Fax: 312-929-0373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04190449
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: