Healthcare Provider Details

I. General information

NPI: 1326595851
Provider Name (Legal Business Name): NICOLE STIVERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 LOUISIANA BLVD NE STE 401
ALBUQUERQUE NM
87110-7020
US

IV. Provider business mailing address

1720 LOUISIANA BLVD NE STE 401
ALBUQUERQUE NM
87110-7020
US

V. Phone/Fax

Practice location:
  • Phone: 505-260-4300
  • Fax: 505-260-4371
Mailing address:
  • Phone: 505-260-4300
  • Fax: 505-260-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000197254
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number082456-23
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01450
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2022035701
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: