Healthcare Provider Details

I. General information

NPI: 1780583443
Provider Name (Legal Business Name): CLARISSA KAY GANNON DFM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 11/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4541 QUARTZ DR NE
RIO RANCHO NM
87124-4910
US

IV. Provider business mailing address

4541 QUARTZ DR NE
RIO RANCHO NM
87124-4910
US

V. Phone/Fax

Practice location:
  • Phone: 505-377-0059
  • Fax:
Mailing address:
  • Phone: 404-377-0059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberBCDFM87101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: