Healthcare Provider Details

I. General information

NPI: 1992451249
Provider Name (Legal Business Name): JAN KRISTY COLANZE SENERICHES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NELSON AVE APT 1105
FARMINGTON NM
87401-3335
US

IV. Provider business mailing address

400 NELSON AVE APT 1105
FARMINGTON NM
87401-3335
US

V. Phone/Fax

Practice location:
  • Phone: 505-436-9688
  • Fax:
Mailing address:
  • Phone: 505-436-9688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0300X
TaxonomyNephrology Registered Nurse
License NumberRN-84262
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: