Provider Demographics
NPI:1225567449
Name:LLEWELLYN, IRASEMA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:IRASEMA
Middle Name:
Last Name:LLEWELLYN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5362
Mailing Address - Fax:505-923-5362
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily