Provider Demographics
NPI:1417186560
Name:MUGAVIN, MARIE ELIZABETH (PHD, FNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELIZABETH
Last Name:MUGAVIN
Suffix:
Gender:F
Credentials:PHD, FNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SKYLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059
Mailing Address - Country:US
Mailing Address - Phone:505-379-8257
Mailing Address - Fax:505-856-6320
Practice Address - Street 1:4810 HARDWARE DR.
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-379-8257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR39817363LF0000X
NMCNP00879363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000A5326Medicaid
NMNMA101340Medicare PIN