{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"LastName": null,
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"FirstLineMailingAddress": "96 LOS ALTOS DE CICUYE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PECOS",
"MailingAddressStateName": "NM",
"MailingAddressPostalCode": "87552-2555",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "505-310-6974",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1640 OLD PECOS TRL STE E&F",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "SANTA FE",
"PracticeLocationAddressStateName": "NM",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "505-310-6974",
"PracticeLocationAddressFaxNumber": "855-795-1933",
"EnumerationDate": "12/19/2020",
"LastUpdateDate": "12/19/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SMITH",
"AuthorizedOfficialFirstName": "SALLY",
"AuthorizedOfficialMiddleName": "ANNE",
"AuthorizedOfficialTitle": "NURSE PRACTITIONER",
"AuthorizedOfficialNamePrefix": "MS.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "FNP",
"AuthorizedOfficialTelephoneNumber": "505-570-7858",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}