Healthcare Provider Details

I. General information

NPI: 1609361013
Provider Name (Legal Business Name): ADRIANA SUZANNE BOULTON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

1100 RIDGECREST DR SE
ALBUQUERQUE NM
87108-3458
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2800
  • Fax:
Mailing address:
  • Phone: 575-496-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number74944
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: