Healthcare Provider Details

I. General information

NPI: 1376377424
Provider Name (Legal Business Name): KRISTIN DEANNA PANTEA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 JACKIE RD SE STE 400
RIO RANCHO NM
87124-1045
US

IV. Provider business mailing address

PO BOX 51566
ALBUQUERQUE NM
87181-1566
US

V. Phone/Fax

Practice location:
  • Phone: 505-862-6523
  • Fax:
Mailing address:
  • Phone: 505-249-3659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number80599
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: