Healthcare Provider Details

I. General information

NPI: 1972893436
Provider Name (Legal Business Name): VERNA ANN KENNETH BA, LSAA, CMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 04/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORTH 371 SOUTHWEST HIGHLAND DRIVE
CROWNPOINT NM
87313
US

IV. Provider business mailing address

BOX 1144 SOUTHWEST HIGHLAND DRIVE
CROWNPOINT NM
87313-1144
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-2111
  • Fax: 505-786-5442
Mailing address:
  • Phone: 505-786-2111
  • Fax: 505-786-5442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0138591
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number0138591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: