Healthcare Provider Details

I. General information

NPI: 1669233789
Provider Name (Legal Business Name): MUSTANG MANAGEMENT GROUP TR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1219
ALBUQUERQUE NM
87102-5340
US

IV. Provider business mailing address

500 MARQUETTE AVE NW STE 1219
ALBUQUERQUE NM
87102-5340
US

V. Phone/Fax

Practice location:
  • Phone: 505-316-5966
  • Fax: 505-422-4073
Mailing address:
  • Phone: 505-316-5966
  • Fax: 505-422-4073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AMBER BLACKNALL
Title or Position: OWNER
Credential: DNP, PMHNP
Phone: 505-316-5966