Healthcare Provider Details

I. General information

NPI: 1407629520
Provider Name (Legal Business Name): ADDISON ANN RAUCH CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 JEFFERSON LN NE
ALBUQUERQUE NM
87109-2127
US

IV. Provider business mailing address

6320 RIVERSIDE PLAZA LN NW STE B
ALBUQUERQUE NM
87120-1710
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-6168
  • Fax:
Mailing address:
  • Phone: 505-843-6168
  • Fax: 505-792-1978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number70297
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: