Healthcare Provider Details

I. General information

NPI: 1497762983
Provider Name (Legal Business Name): KATHY REBECCA FRESQUEZ-CHAVEZ C.F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 MAIN ST NE
LOS LUNAS NM
87031-7454
US

IV. Provider business mailing address

PO BOX 486
LOS LUNAS NM
87031-0486
US

V. Phone/Fax

Practice location:
  • Phone: 505-916-5167
  • Fax: 505-916-5170
Mailing address:
  • Phone: 505-916-5167
  • Fax: 505-916-5170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR37352
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: