Healthcare Provider Details

I. General information

NPI: 1346335759
Provider Name (Legal Business Name): FATEMEH MANSOORI C.F.N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9334
US

IV. Provider business mailing address

2230 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9334
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-0300
  • Fax:
Mailing address:
  • Phone: 505-869-0300
  • Fax: 505-869-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCS00210250
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: