Healthcare Provider Details

I. General information

NPI: 1871838078
Provider Name (Legal Business Name): REBECCA ANNE OTERO-GRANGER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ISLETA BLVD SW
ALBUQUERQUE NM
87105-3896
US

IV. Provider business mailing address

1504 N MESA RD
BELEN NM
87002-8528
US

V. Phone/Fax

Practice location:
  • Phone: 505-200-2647
  • Fax: 505-200-2695
Mailing address:
  • Phone: 505-350-1035
  • Fax: 505-200-2695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNP-02087
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: