Healthcare Provider Details

I. General information

NPI: 1114846615
Provider Name (Legal Business Name): RU SI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S SCHWARTZ AVE STE 202
FARMINGTON NM
87401-5925
US

IV. Provider business mailing address

204 E VALLEY VIEW DR
BAYFIELD CO
81122-9297
US

V. Phone/Fax

Practice location:
  • Phone: 505-609-6770
  • Fax:
Mailing address:
  • Phone: 573-275-9396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.1002112-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: