Healthcare Provider Details

I. General information

NPI: 1780799452
Provider Name (Legal Business Name): LAURIE L VIGNE RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE L YELVINGTON RN, CDE

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST ESPANOLA MULTI-SPECIALTY CLINIC
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-8031
  • Fax: 505-753-7433
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License NumberR27926
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR27926
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: