Healthcare Provider Details

I. General information

NPI: 1407639933
Provider Name (Legal Business Name): BREAWNNA BLAESING WUNDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 GUSDORF RD
TAOS NM
87571-6282
US

IV. Provider business mailing address

1331 GUSDORF RD
TAOS NM
87571-6282
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-3601
  • Fax: 505-579-4669
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number79552
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN-79465
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: