Healthcare Provider Details

I. General information

NPI: 1740872001
Provider Name (Legal Business Name): DAWNELLE ROMERO-BACA DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

3300 GRASSY CT SW
ALBUQUERQUE NM
87121-2185
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-948-6995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number62852
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: