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General NPI Number Information
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NPI Number | 1013737261
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Entity Type | Organization
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Legal Business Name | CHEVANNES CLINIC SOLUTIONS, LLC
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Dates
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Enumeration Date | 10/14/2024
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 817 W BROADWAY STE A
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City | FARMINGTON
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State | NM
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Zip | 87401-5699
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Country | US
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Telephone | 505-258-4867
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Fax | 505-398-8748
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Provider Business Mailing Address
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Address Line | 817 W BROADWAY STE A
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City | FARMINGTON
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State | NM
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Zip | 87401-5699
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Country | US
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Telephone | 505-258-4867
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Fax | 505-398-8748
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Authorized Official
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Title or Position | NURSE PRACTITIONER/OWNER
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Name | ANGELLA DIONNE CLARKE
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Credential | NURSE PRACTITIONER
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Telephone | 505-258-4867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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