MEDICARE: MRS. LYNNET M BULAMBO PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	58185	NM

General Provider Information

NPI Number	:	1063891307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNNET M BULAMBO PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 8244
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88202-8244
Country	:	US
Telephone Number	:	575-755-5555
Fax Number	:	575-755-5556

Provider Business Practice Location Address
First Line	:	613 W 2ND ST # 1&3
Second Line	:
City	:	ROSWELL
State	:	NM
Zip	:	88201-4671
Country	:	US
Telephone Number	:	210-900-0729
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	12/26/2019

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