Healthcare Provider Details

I. General information

NPI: 1831437441
Provider Name (Legal Business Name): VANESSA'S FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 E WOOD AVE
CARLSBAD NM
88220-6500
US

IV. Provider business mailing address

402 E WOOD AVE
CARLSBAD NM
88220-6500
US

V. Phone/Fax

Practice location:
  • Phone: 575-941-5000
  • Fax: 575-941-2503
Mailing address:
  • Phone: 575-941-5000
  • Fax: 575-941-2503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01226
License Number StateNM

VIII. Authorized Official

Name: MRS. VANESSA GREEN
Title or Position: FAMILY NURSE PRACTITIONER
Credential: FNP
Phone: 575-941-2500