Healthcare Provider Details

I. General information

NPI: 1467051060
Provider Name (Legal Business Name): AUDREY G LIETZKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SUTTER PL
CLOVIS NM
88101-4611
US

IV. Provider business mailing address

PO BOX 19000
CLOVIS NM
88102-9000
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-4490
  • Fax: 575-769-4430
Mailing address:
  • Phone: 575-769-4490
  • Fax: 575-769-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number1116422
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: