Healthcare Provider Details

I. General information

NPI: 1972219210
Provider Name (Legal Business Name): ALISH MCBRIDE CASSIDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 WYOMING BLVD NE
ALBUQUERQUE NM
87109-3167
US

IV. Provider business mailing address

713 INDIANA ST SE
ALBUQUERQUE NM
87108-3812
US

V. Phone/Fax

Practice location:
  • Phone: 443-926-6537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: