Healthcare Provider Details

I. General information

NPI: 1497009203
Provider Name (Legal Business Name): KOURTNEY ANNA CHAIRES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2012
Last Update Date: 02/12/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 ABERDEEN AVE
WHITE SANDS MISSILE RANGE NM
88002
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-674-3500
  • Fax: 915-742-7459
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02110
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: