Healthcare Provider Details

I. General information

NPI: 1780270280
Provider Name (Legal Business Name): JENNY B NATION FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2020
Last Update Date: 03/04/2024
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 NATIONAL AVE
LAS VEGAS NM
87701-4243
US

IV. Provider business mailing address

611 NATIONAL AVE
LAS VEGAS NM
87701-4243
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-0700
  • Fax: 505-426-0702
Mailing address:
  • Phone: 505-426-0070
  • Fax: 505-426-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-62327
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62327
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: