Healthcare Provider Details

I. General information

NPI: 1649671918
Provider Name (Legal Business Name): LISA CANDELARIA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax: 505-443-8314
Mailing address:
  • Phone: 505-896-0928
  • Fax: 505-443-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: