Healthcare Provider Details

I. General information

NPI: 1447423926
Provider Name (Legal Business Name): HEATHER L OUELLETTE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL NW
LOS LUNAS NM
87031-6601
US

IV. Provider business mailing address

145 DON PASQUAL NW
LOS LUNAS NM
87031-6601
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4618
  • Fax: 505-224-8727
Mailing address:
  • Phone: 505-865-4618
  • Fax: 505-224-8727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2011-0554
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: