Healthcare Provider Details

I. General information

NPI: 1417842899
Provider Name (Legal Business Name): CAMILLE VIOLET VENCZEL-LOONAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-539-4735
  • Fax:
Mailing address:
  • Phone: 505-359-9041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSWB-2025-0483
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: