Healthcare Provider Details

I. General information

NPI: 1861711814
Provider Name (Legal Business Name): JANE E. PENROD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4907 MARBLE AVE NE
ALBUQUERQUE NM
87110-6345
US

IV. Provider business mailing address

4907 MARBLE AVE NE
ALBUQUERQUE NM
87110-6345
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1648
  • Fax:
Mailing address:
  • Phone: 505-265-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNS-00218
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: