Healthcare Provider Details

I. General information

NPI: 1487010237
Provider Name (Legal Business Name): LINDA RAE OWEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2016
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 LINCOLN WAY
CAPITAN NM
88316
US

IV. Provider business mailing address

PO BOX 729
CAPITAN NM
88316-0729
US

V. Phone/Fax

Practice location:
  • Phone: 575-354-0057
  • Fax: 575-354-0056
Mailing address:
  • Phone: 575-354-0057
  • Fax: 505-354-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02755
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-02755
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: