=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689486003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE DANIELLE MANSOUR FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2025
-----------------------------------------------------
Last Update Date | 08/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7801 ACADEMY RD NE BLDG 2 SUITE 104
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-3379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-730-5020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2318 GARDEN RD NE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-2431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-459-4602
-----------------------------------------------------
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 | 82459
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------