Provider Demographics
NPI:1558457309
Name:GUTIERREZ SISNEROS, ANNABELLE X (APRN, BC MSN CCM MA)
Entity Type:Individual
Prefix:MS
First Name:ANNABELLE
Middle Name:X
Last Name:GUTIERREZ SISNEROS
Suffix:
Gender:F
Credentials:APRN, BC MSN CCM MA
Other - Prefix:MRS
Other - First Name:ANA
Other - Middle Name:GUTIERREZ
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, ADN BSN
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:1120 INDUSTRIAL PARK RD., SUITE 401
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0000
Mailing Address - Country:US
Mailing Address - Phone:505-690-0213
Mailing Address - Fax:505-747-2965
Practice Address - Street 1:1120 INDUSTRIAL PARK RD, SUITE 401
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-0000
Practice Address - Country:US
Practice Address - Phone:505-690-0213
Practice Address - Fax:505-747-2965
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR22377364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59870788Medicaid