Provider Demographics
NPI:1417584897
Name:FISHER, KACIE LEANNA (NP)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:LEANNA
Last Name:FISHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:719 SAN MATEO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1434
Mailing Address - Country:US
Mailing Address - Phone:505-485-0464
Mailing Address - Fax:505-266-1017
Practice Address - Street 1:1560 12TH ST STE 7
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-3709
Practice Address - Country:US
Practice Address - Phone:719-589-4906
Practice Address - Fax:719-589-3034
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM58949363LW0102X
COC-APN.0001928-C-NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000182582Medicaid
NM42636256Medicaid
COC-APN.0001928-C-NPOtherCOLORADO LICENSE
NM58949OtherNEW MEXICO LICENSE