Healthcare Provider Details

I. General information

NPI: 1841908811
Provider Name (Legal Business Name): JACQUELYNN LOPEZ GUERIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10124 COORS BLVD NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

10705 FLAGSTONE PL NW
ALBUQUERQUE NM
87114-3995
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-8622
  • Fax:
Mailing address:
  • Phone: 505-263-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65744
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: