Healthcare Provider Details

I. General information

NPI: 1790214344
Provider Name (Legal Business Name): LA PALOMA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 GENE AVE NW
ALBUQUERQUE NM
87107-5320
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 505-384-7352
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: LISA ATWA
Title or Position: CNP/OWNER
Credential:
Phone: 505-384-7352