Provider Demographics
NPI:1083293104
Name:LANDRETH, PATRICIA L (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2402 W PIERCE ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3568
Mailing Address - Country:US
Mailing Address - Phone:575-887-0637
Mailing Address - Fax:575-887-0638
Practice Address - Street 1:2402 W PIERCE ST STE 2A
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3568
Practice Address - Country:US
Practice Address - Phone:575-887-0637
Practice Address - Fax:575-887-0638
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM63661207Q00000X
NMF03211422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine