MEDICARE: CALEY NICOLE DENEVERS FNP-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	363LF0000X	Family Nurse Practitioner	53418	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	53418	OTHER	NM	NEW MEXICO BOARD OF NURSING

General Provider Information

NPI Number	:	1093332587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALEY NICOLE DENEVERS FNP-BC

Provider Business Mailing Address
First Line	:	611 NATIONAL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4243
Country	:	US
Telephone Number	:	505-426-0700
Fax Number	:	505-426-0702

Provider Business Practice Location Address
First Line	:	611 NATIONAL AVE
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4243
Country	:	US
Telephone Number	:	505-426-0700
Fax Number	:	505-426-0702

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

Provider Enumeration Date	:	06/30/2020
Last Update Date	:	06/30/2020

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