Healthcare Provider Details

I. General information

NPI: 1346480035
Provider Name (Legal Business Name): ERIN R NELSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERIN R LICHTY RD

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022
US

IV. Provider business mailing address

P.O BOX 640
ISLETA NM
87022
US

V. Phone/Fax

Practice location:
  • Phone: 214-348-5557
  • Fax: 214-348-5898
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT80500
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-0865
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: