Healthcare Provider Details

I. General information

NPI: 1194154823
Provider Name (Legal Business Name): VIVIENNE PRINZ CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 QUAIL TRL UNIT B
EDGEWOOD NM
87015-7185
US

IV. Provider business mailing address

104 QUAIL TRL UNIT B
EDGEWOOD NM
87015-7185
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-0204
  • Fax:
Mailing address:
  • Phone: 505-286-2396
  • Fax: 505-286-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02281
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: