Healthcare Provider Details

I. General information

NPI: 1588653323
Provider Name (Legal Business Name): ANN MARIE MCCARTHY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COUNTY ROAD 6788
FRUITLAND NM
87416
US

IV. Provider business mailing address

PO BOX 1015
WATERFLOW NM
87421-1015
US

V. Phone/Fax

Practice location:
  • Phone: 505-320-5209
  • Fax:
Mailing address:
  • Phone: 505-320-5209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00650
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: