Healthcare Provider Details

I. General information

NPI: 1255845293
Provider Name (Legal Business Name): JENNA LINDSAY GORMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 2ND ST
LOGAN NM
88426-8842
US

IV. Provider business mailing address

PO BOX 272
LOGAN NM
88426-0272
US

V. Phone/Fax

Practice location:
  • Phone: 575-487-2252
  • Fax: 575-487-9479
Mailing address:
  • Phone: 575-403-6512
  • Fax: 575-487-9479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberRN-81143
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: