Healthcare Provider Details

I. General information

NPI: 1336648328
Provider Name (Legal Business Name): DESIREE RENEE PROVENCIO DNP, CNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9384 VALLEY VIEW DR NW STE 400
ALBUQUERQUE NM
87114-4403
US

IV. Provider business mailing address

PO BOX 45450
RIO RANCHO NM
87174-5450
US

V. Phone/Fax

Practice location:
  • Phone: 505-225-3110
  • Fax: 505-207-7988
Mailing address:
  • Phone: 505-225-3110
  • Fax: 505-207-7988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-03491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: