=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902468861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH MORAN CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2019
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 MONTANO RD NW STE A1
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-777-3003
-----------------------------------------------------
Fax | 505-808-4976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740018
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-0018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-733-9730
-----------------------------------------------------
Fax | 773-866-8014
-----------------------------------------------------
=====================================================
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 | 56735
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------