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General NPI Number Information
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NPI Number | 1336648328
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Entity Type | Individual
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Provider Name | DESIREE RENEE PROVENCIO DNP, CNP, PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 02/06/2018
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 9384 VALLEY VIEW DR NW STE 400
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-4403
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Country | US
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Telephone | 505-225-3110
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Fax | 505-207-7988
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Provider Business Mailing Address
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Address Line | PO BOX 45450
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City | RIO RANCHO
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State | NM
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Zip | 87174-5450
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Country | US
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Telephone | 505-225-3110
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Fax | 505-207-7988
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP-03491
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License Number State | NM
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