Healthcare Provider Details

I. General information

NPI: 1124752738
Provider Name (Legal Business Name): COMMON GROUND COMMUNITY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 LOS RANCHOS RD NW
LOS RANCHOS NM
87107-6531
US

IV. Provider business mailing address

332 LOS RANCHOS RD NW
LOS RANCHOS NM
87107-6531
US

V. Phone/Fax

Practice location:
  • Phone: 952-913-6422
  • Fax:
Mailing address:
  • Phone: 952-913-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANN ROBINSON
Title or Position: OWNER/PROVIDER
Credential: CNP
Phone: 952-913-6422