Healthcare Provider Details

I. General information

NPI: 1760197487
Provider Name (Legal Business Name): KOURTNEY S BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 BECKNER RD
SANTA FE NM
87507-3774
US

IV. Provider business mailing address

2800 S MEADOWS RD UNIT 623
SANTA FE NM
87507-3682
US

V. Phone/Fax

Practice location:
  • Phone: 505-477-2200
  • Fax: 505-782-1902
Mailing address:
  • Phone: 318-554-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD22006
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: