| NPI | 1396464723 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DESIREE R PROVENCIO Member/Manager 505-225-3110 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health |
| Enumeration Date | 2022-08-29 |
| Last Update Date | 2025-10-17 |