Healthcare Provider Details

I. General information

NPI: 1669155495
Provider Name (Legal Business Name): MIRNA M CHAVEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 N MAIN ST
SPANISH FORK UT
84660-1008
US

IV. Provider business mailing address

PO BOX 26028
ALBUQUERQUE NM
87125-6028
US

V. Phone/Fax

Practice location:
  • Phone: 855-817-4687
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number75887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: