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General NPI Number Information
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NPI Number | 1528429438
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Entity Type | Organization
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Legal Business Name | COTTONWOOD FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 03/19/2016
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Last Update Date | 03/19/2016
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Provider Practice Location Address
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Address Line | 4940 CORRALES RD SUITE 200
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City | CORRALES
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State | NM
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Zip | 87048-8673
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Country | US
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Telephone | 505-929-0663
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Fax |
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Provider Business Mailing Address
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Address Line | 7117 HAPSBURG RD NE
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City | RIO RANCHO
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State | NM
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Zip | 87144-6608
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Country | US
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Telephone | 505-929-0663
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER/NURSE PRACTITIONER
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Name | KATIE BOYLAN
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Credential | CNP
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Telephone | 505-929-0663
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | CNP02459
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License Number State | NM
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