Healthcare Provider Details

I. General information

NPI: 1487340212
Provider Name (Legal Business Name): CAROLINE ELIZABETH WANNER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 CERRILLOS RD STE 300
SANTA FE NM
87507-4418
US

IV. Provider business mailing address

8801 HORIZON BLVD NE STE 360
ALBUQUERQUE NM
87113-1563
US

V. Phone/Fax

Practice location:
  • Phone: 505-375-8955
  • Fax: 505-404-0795
Mailing address:
  • Phone: 505-246-2622
  • Fax: 505-715-5334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-2025-0015
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618003248
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: