Healthcare Provider Details

I. General information

NPI: 1083610554
Provider Name (Legal Business Name): GWEN RENEE WILLIAMS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 CALLE DE ALVAREZ STE B
LAS CRUCES NM
88005-3821
US

IV. Provider business mailing address

1680 CALLE DE ALVAREZ STE B
LAS CRUCES NM
88005-3821
US

V. Phone/Fax

Practice location:
  • Phone: 575-524-3346
  • Fax: 575-524-1720
Mailing address:
  • Phone: 575-524-3346
  • Fax: 575-524-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR50209
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: