=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487478541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANA ROSE BENAD CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2019 GALISTEO ST STE A3
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-988-2117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2019 GALISTEO ST STE A3
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-988-2117
-----------------------------------------------------
Fax | 505-988-2119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 81411
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------