Healthcare Provider Details

I. General information

NPI: 1871624734
Provider Name (Legal Business Name): NANCI LEE MON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CAMINO SIERRA VISTA BF YOUNG PROFESSIONAL BLDG.
SANTA FE NM
87505
US

IV. Provider business mailing address

PO BOX 9917
SANTA FE NM
87504-5917
US

V. Phone/Fax

Practice location:
  • Phone: 505-467-2503
  • Fax: 505-989-5568
Mailing address:
  • Phone: 505-982-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: