Provider Demographics
NPI:1376685545
Name:VELARDE, SUSAN ANN
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:ANN
Last Name:VELARDE
Suffix:
Gender:F
Credentials:
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 804
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0804
Mailing Address - Country:US
Mailing Address - Phone:505-759-7246
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZI1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherIllustration, Medical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid