Healthcare Provider Details

I. General information

NPI: 1477504959
Provider Name (Legal Business Name): JEANNINE M ACANTILADO CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

5901 HARPER DR NE
ALBUQUERQUE NM
87109-3587
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1819
  • Fax: 505-841-1998
Mailing address:
  • Phone: 505-823-8556
  • Fax: 505-823-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR54517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: