Healthcare Provider Details

I. General information

NPI: 1942290283
Provider Name (Legal Business Name): JACQUELINE ANNE KROHN MD MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD SUITE 136
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

3917 WEST RD SUITE 136
LOS ALAMOS NM
87544-2275
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-9620
  • Fax: 505-662-0024
Mailing address:
  • Phone: 505-662-9620
  • Fax: 505-662-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number79195
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: