Healthcare Provider Details

I. General information

NPI: 1144323353
Provider Name (Legal Business Name): JENNIFER LEA LEA CLAYCOMB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH MUNDO
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 187
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax: 505-759-3532
Mailing address:
  • Phone: 505-759-3291
  • Fax: 505-759-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2005019602
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: