Provider Demographics
NPI:1336648328
Name:PROVENCIO, DESIREE RENEE (DNP, CNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:RENEE
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:DNP, CNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 RIVERSIDE PLAZA LN NW STE 100
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1908
Mailing Address - Country:US
Mailing Address - Phone:505-225-3110
Mailing Address - Fax:505-207-7988
Practice Address - Street 1:6300 RIVERSIDE PLAZA LN NW STE 100
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1908
Practice Address - Country:US
Practice Address - Phone:505-225-3110
Practice Address - Fax:505-207-7988
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-03491363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCNP-03491OtherNEW MEXICO BOARD OF NURSING CNP LICENSURE