Healthcare Provider Details

I. General information

NPI: 1427140474
Provider Name (Legal Business Name): LINDA LUCY BOULANGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 CERRILLOS RD
SANTA FE NM
87505-3554
US

IV. Provider business mailing address

1522 CERRO GORDO RD
SANTA FE NM
87501-6143
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-9821
  • Fax:
Mailing address:
  • Phone: 505-982-9002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number98-18
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: