Healthcare Provider Details

I. General information

NPI: 1396574380
Provider Name (Legal Business Name): KATHRYN WHITTAKER AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5981 JEFFERSON ST NE STE A
ALBUQUERQUE NM
87109-3457
US

IV. Provider business mailing address

5981 JEFFERSON ST NE STE A
ALBUQUERQUE NM
87109-3457
US

V. Phone/Fax

Practice location:
  • Phone: 505-370-9600
  • Fax:
Mailing address:
  • Phone: 505-370-9600
  • Fax: 505-355-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number55280
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: