Doctor Name: | JODI A. DETTMAN |
NPI Number: | 1720269178 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | CNP |
License Number: | CNP01152 |
Business Practice Address: | 1108 W Us Route 66 Moriarty, NM - 870351006 |
Business Phone Number: | 5058324434 |
Business Fax Number: | |
Mailing Address: | 1108 Us Route 66 West, MORIARTY |
State: | NM |
Postal Code: | 870351520 |
Phone Number: | 5058324434 |
Fax Number: | |
NPI Enumeration Date: | 11/14/2007 |
NPI Last Update Date: | 07/15/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LA2200X |
License Number: | CNP01152 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NM |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Adult Health |
Taxonomy Definition: |