Healthcare Provider Details

I. General information

NPI: 1255135547
Provider Name (Legal Business Name): MICHELL LEE COSGROVE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

6753 KELLY ANN RD NE
ALBUQUERQUE NM
87109-3768
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 832-628-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number83158
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: