Healthcare Provider Details

I. General information

NPI: 1487375689
Provider Name (Legal Business Name): JOANNA MARIE CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 DON PASQUAL RD NW
LOS LUNAS NM
87031-8493
US

IV. Provider business mailing address

239 ELM ST NE
ALBUQUERQUE NM
87102-3672
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-5944
  • Fax:
Mailing address:
  • Phone: 505-242-1010
  • Fax: 505-242-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: