Provider Demographics
NPI:1346335759
Name:MANSOORI, FATEMEH (CFNP)
Entity Type:Individual
Prefix:
First Name:FATEMEH
Middle Name:
Last Name:MANSOORI
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 BOSQUE FARMS BLVD
Mailing Address - Street 2:
Mailing Address - City:BOSQUE FARMS
Mailing Address - State:NM
Mailing Address - Zip Code:87068-9334
Mailing Address - Country:US
Mailing Address - Phone:505-869-0300
Mailing Address - Fax:505-869-0311
Practice Address - Street 1:2230 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9334
Practice Address - Country:US
Practice Address - Phone:505-869-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCS00210250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM349531402Medicare ID - Type Unspecified