Healthcare Provider Details

I. General information

NPI: 1376326199
Provider Name (Legal Business Name): MIRABEL CHISOM IJEOMAH DNP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6709 ACADEMY RD NE STE A
ALBUQUERQUE NM
87109-3363
US

IV. Provider business mailing address

2301 WESTSIDE BLVD SE APT 219
RIO RANCHO NM
87124-5146
US

V. Phone/Fax

Practice location:
  • Phone: 773-899-1586
  • Fax:
Mailing address:
  • Phone: 919-896-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number91374
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: