=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316184831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIQUE Y KEULEN-NOLET FNP RN MSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2009
-----------------------------------------------------
Last Update Date | 03/06/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12127B NORTH HIGHWAY 14 SUITE #5
-----------------------------------------------------
City | CEDAR CREST
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-281-2460
-----------------------------------------------------
Fax | 505-281-2463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 EL CIELO AZUL CIR
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015-7916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-281-8493
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R 34614
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------