Healthcare Provider Details

I. General information

NPI: 1558457309
Provider Name (Legal Business Name): ANNABELLE X. GUTIERREZ SISNEROS APRN, BC MSN CCM MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANA GUTIERREZ MORA RN, ADN BSN

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 INDUSTRIAL PARK RD, SUITE 401
ESPANOLA NM
87532-0000
US

IV. Provider business mailing address

PO BOX 1845 1120 INDUSTRIAL PARK RD., SUITE 401
ESPANOLA NM
87532-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-0213
  • Fax: 505-747-2965
Mailing address:
  • Phone: 505-690-0213
  • Fax: 505-747-2965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR22377
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: