MEDICARE: LEOTA MERLE JENTZEN APRN-CNS

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	55391	NM

General Provider Information

NPI Number	:	1548729296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEOTA MERLE JENTZEN APRN-CNS

Provider Business Mailing Address
First Line	:	800 BRADBURY DR SE STE 116
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4310
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6020 SILVER LEAF TRL NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-8095
Country	:	US
Telephone Number	:	806-640-2790
Fax Number	:

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

Provider Enumeration Date	:	03/12/2019
Last Update Date	:	01/28/2026

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