Healthcare Provider Details

I. General information

NPI: 1871100537
Provider Name (Legal Business Name): ADRIENE HARRELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264 RODEO RD
SANTA FE NM
87505-6816
US

IV. Provider business mailing address

1264 RODEO RD
SANTA FE NM
87505-6816
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-2129
  • Fax:
Mailing address:
  • Phone: 505-982-2129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002075858
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: