Healthcare Provider Details

I. General information

NPI: 1184636698
Provider Name (Legal Business Name): SANDY GAIL PHELPS-CANZONE D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 GALISTEO ST UNIT A2
SANTA FE NM
87505-2138
US

IV. Provider business mailing address

2074 GALISTEO ST UNIT A2
SANTA FE NM
87505-2138
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-7418
  • Fax: 505-986-8874
Mailing address:
  • Phone: 505-989-7418
  • Fax: 505-986-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number671RX1
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: