Healthcare Provider Details

I. General information

NPI: 1497237077
Provider Name (Legal Business Name): HOLLY BURKS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S 9TH ST
BELEN NM
87002-3102
US

IV. Provider business mailing address

120 S 9TH ST
BELEN NM
87002-3102
US

V. Phone/Fax

Practice location:
  • Phone: 505-861-1013
  • Fax:
Mailing address:
  • Phone: 505-861-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53821
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: