Healthcare Provider Details

I. General information

NPI: 1649720822
Provider Name (Legal Business Name): JANET CREELMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAISIE CREELMAN

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 MAIN ST NW
LOS LUNAS NM
87031-8712
US

IV. Provider business mailing address

2704 MCEARL AVE SE
ALBUQUERQUE NM
87106-3009
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-8338
  • Fax:
Mailing address:
  • Phone: 505-280-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number3597
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number377103
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: