Healthcare Provider Details

I. General information

NPI: 1144717075
Provider Name (Legal Business Name): VDEX DIABETES NM-BROWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 N RIVERSIDE DR STE C
ESPANOLA NM
87532-9550
US

IV. Provider business mailing address

1811 N RIVERSIDE DR STE C
ESPANOLA NM
87532-9550
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-0506
  • Fax: 505-747-0507
Mailing address:
  • Phone: 505-747-0506
  • Fax: 505-747-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE SHARON BROWN
Title or Position: PROVIDER
Credential: CNP
Phone: 303-483-8967