MEDICARE: LAURIE L VIGNE RN, CDE

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	132700000X	Dietary Manager	R27926	NM
2	163WD0400X	Diabetes Educator Registered Nurse	R27926	NM

General Provider Information

NPI Number	:	1780799452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE L VIGNE RN, CDE

Provider Business Mailing Address
First Line	:	PO BOX 26666
Second Line	:	PHS PROVIDER ENROLLMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87125-6666
Country	:	US
Telephone Number	:	505-923-6770
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 SPRUCE ST
Second Line	:	ESPANOLA MULTI-SPECIALTY CLINIC
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2724
Country	:	US
Telephone Number	:	505-753-8031
Fax Number	:	505-753-7433

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	01/08/2021

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