Provider Demographics
NPI:1326029240
Name:BOTNE, PROVIDENCE MUSOMANDERA (RN)
Entity Type:Individual
Prefix:MS
First Name:PROVIDENCE
Middle Name:MUSOMANDERA
Last Name:BOTNE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10712 CENTRAL PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-4849
Mailing Address - Country:US
Mailing Address - Phone:505-292-4144
Mailing Address - Fax:
Practice Address - Street 1:2600 MARBLE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87151-0001
Practice Address - Country:US
Practice Address - Phone:505-839-8839
Practice Address - Fax:505-839-8989
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53622163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR53622OtherR.N.LICENCE