=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588486989
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINE SUZANNE ELLIS NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 E AVE FAMILY MEDICINE
-----------------------------------------------------
City | CARRIZOZO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88301-0008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-648-2317
-----------------------------------------------------
Fax | 575-648-4413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26666
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87125-6666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-740-7449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 81488
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------