=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679208052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATE ELIZABETH NELSON FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2022
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1035 ALTO ST
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-231-3217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1464 MIRACERROS LOOP N
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-231-3217
-----------------------------------------------------
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 | 69040
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------