Healthcare Provider Details

I. General information

NPI: 1912721242
Provider Name (Legal Business Name): JOHANNA PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 S PACHECO ST STE 500
SANTA FE NM
87505-3994
US

IV. Provider business mailing address

901 RIO GRANDE BLVD NW STE G252
ALBUQUERQUE NM
87104-2050
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8112
  • Fax: 505-355-2611
Mailing address:
  • Phone: 505-702-8112
  • Fax: 505-355-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: