Healthcare Provider Details

I. General information

NPI: 1306952932
Provider Name (Legal Business Name): LA JUANA DELL WILLIS CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GALLEGOS
LOGAN NM
88426-7602
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-487-9000
  • Fax: 575-487-9002
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP00145
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR14626
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: