Healthcare Provider Details

I. General information

NPI: 1083831051
Provider Name (Legal Business Name): JESSICA CHYNOWETH M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4385
  • Fax:
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRS20070280
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: