Healthcare Provider Details

I. General information

NPI: 1154879757
Provider Name (Legal Business Name): KATELYN LIEBENSTEIN CNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 HARKLE RD STE E
SANTA FE NM
87505-4765
US

IV. Provider business mailing address

649 HARKLE RD STE E
SANTA FE NM
87505-4765
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-8200
  • Fax: 505-216-9067
Mailing address:
  • Phone: 505-989-8200
  • Fax: 505-989-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: