Provider Demographics
NPI:1407231772
Name:BACA, JOANN (RN)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:BACA
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 1:601 GOEBEL AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3619
Mailing Address - Country:US
Mailing Address - Phone:505-715-9200
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3720
Practice Address - Country:US
Practice Address - Phone:505-966-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR58266163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse