Healthcare Provider Details

I. General information

NPI: 1992914501
Provider Name (Legal Business Name): JENIFER LICHTENFELS, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MISSOURI AVE
LAS CRUCES NM
88011-5075
US

IV. Provider business mailing address

PO BOX 1560
LAS CRUCES NM
88004-1560
US

V. Phone/Fax

Practice location:
  • Phone: 505-521-0630
  • Fax: 505-521-0628
Mailing address:
  • Phone: 505-647-8366
  • Fax: 505-647-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number88211
License Number StateNM

VIII. Authorized Official

Name: KATRINA MARIE FERRALES
Title or Position: CREDENTIALING
Credential:
Phone: 505-647-8366