=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487010237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA RAE OWEN FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2016
-----------------------------------------------------
Last Update Date | 05/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 LINCOLN WAY
-----------------------------------------------------
City | CAPITAN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-354-0057
-----------------------------------------------------
Fax | 575-354-0056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 729
-----------------------------------------------------
City | CAPITAN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88316-0729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-354-0057
-----------------------------------------------------
Fax | 505-354-0056
-----------------------------------------------------
=====================================================
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 | CNP-02755
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CNP-02755
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------