Healthcare Provider Details

I. General information

NPI: 1477077345
Provider Name (Legal Business Name): CHARISSE BUCHANAN AG-NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2017
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 COLLEGE BLVD
FARMINGTON NM
87402-4699
US

IV. Provider business mailing address

4601 COLLEGE BLVD
FARMINGTON NM
87402-4699
US

V. Phone/Fax

Practice location:
  • Phone: 505-566-4255
  • Fax: 505-566-3770
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP-03322
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: