Healthcare Provider Details

I. General information

NPI: 1841596608
Provider Name (Legal Business Name): SONDA SUE BOULWARE ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 S TELSHOR BLVD BUILDING 14, SUITE 102
LAS CRUCES NM
88011-5071
US

IV. Provider business mailing address

2525 S TELSHOR BLVD STE 102
LAS CRUCES NM
88011-9148
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-7247
  • Fax: 575-522-2029
Mailing address:
  • Phone: 575-522-7247
  • Fax: 575-522-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP-01702
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: