Healthcare Provider Details

I. General information

NPI: 1659800894
Provider Name (Legal Business Name): INTEGRATED HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2017
Last Update Date: 06/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 BARBARA LOOP SE STE C
RIO RANCHO NM
87124-1011
US

IV. Provider business mailing address

4101 BARBARA LOOP SE STE C
RIO RANCHO NM
87124-1011
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-4503
  • Fax: 505-891-1495
Mailing address:
  • Phone: 505-994-4503
  • Fax: 505-891-1495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-0216
License Number StateNM

VIII. Authorized Official

Name: JACQUELINE EVA WILLIS
Title or Position: OWNER
Credential: NP
Phone: 505-994-4503