Healthcare Provider Details

I. General information

NPI: 1770809527
Provider Name (Legal Business Name): URSULA MICHAEL GABRIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 04/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE ROAD
DULCE NM
87528
US

IV. Provider business mailing address

12000 STONE LAKE ROAD
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax: 575-759-7294
Mailing address:
  • Phone: 575-759-3291
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberA026173
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: