Provider Demographics
NPI:1235703521
Name:BACA, MICHELLE DENISE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DENISE
Last Name:BACA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:DENISE
Other - Last Name:TAFOYA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:707 BROADWAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2360
Mailing Address - Country:US
Mailing Address - Phone:505-554-0082
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2360
Practice Address - Country:US
Practice Address - Phone:505-554-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR67797163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse