Healthcare Provider Details

I. General information

NPI: 1700564291
Provider Name (Legal Business Name): STACY ANNETTE CHANG BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N SUNSET AVE
FARMINGTON NM
87401-3421
US

IV. Provider business mailing address

3401 E 30TH ST STE A
FARMINGTON NM
87402-8805
US

V. Phone/Fax

Practice location:
  • Phone: 505-324-0352
  • Fax:
Mailing address:
  • Phone: 505-324-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR36591
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: