Healthcare Provider Details

I. General information

NPI: 1417385337
Provider Name (Legal Business Name): PENELOPE KATHLEEN PRATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 E MAIN ST
FARMINGTON NM
87402-5153
US

IV. Provider business mailing address

3501 E MAIN ST
FARMINGTON NM
87402-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-258-4457
  • Fax:
Mailing address:
  • Phone: 506-258-4457
  • Fax: 413-445-6242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023-0884
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: