Healthcare Provider Details

I. General information

NPI: 1003388190
Provider Name (Legal Business Name): KELLY VAN PFEIFFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2018
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 N LOVINGTON HWY STE 550
HOBBS NM
88240-1171
US

IV. Provider business mailing address

3900 N LOVINGTON HWY STE 550
HOBBS NM
88240-1171
US

V. Phone/Fax

Practice location:
  • Phone: 575-738-0051
  • Fax: 575-291-3009
Mailing address:
  • Phone: 575-964-8025
  • Fax: 575-291-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number54573
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: