=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669233789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUSTANG MANAGEMENT GROUP TR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2024
-----------------------------------------------------
Last Update Date | 01/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 MARQUETTE AVE NW STE 1219
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-316-5966
-----------------------------------------------------
Fax | 505-422-4073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 MARQUETTE AVE NW STE 1219
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-5340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-316-5966
-----------------------------------------------------
Fax | 505-422-4073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMBER BLACKNALL
-----------------------------------------------------
Credential | DNP, PMHNP
-----------------------------------------------------
Telephone | 505-316-5966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------