Healthcare Provider Details

I. General information

NPI: 1669481933
Provider Name (Legal Business Name): NANCY ROSE MAHDAVI APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1191 COMANCHE CT SE
RIO RANCHO NM
87124-3066
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-2819
Mailing address:
  • Phone: 505-891-8674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR 36671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: