Healthcare Provider Details

I. General information

NPI: 1639908577
Provider Name (Legal Business Name): LAUREN ROUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4504
US

IV. Provider business mailing address

1221 SILVER AVE SW APT 22
ALBUQUERQUE NM
87102-2864
US

V. Phone/Fax

Practice location:
  • Phone: 505-361-1009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: