Provider Demographics
NPI:1619532066
Name:WALSH, SONYA M (CNP)
Entity Type:Individual
Prefix:MRS
First Name:SONYA
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:CNP
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 26028
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6028
Mailing Address - Country:US
Mailing Address - Phone:505-232-1617
Mailing Address - Fax:505-262-7729
Practice Address - Street 1:2121 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3307
Practice Address - Country:US
Practice Address - Phone:505-237-8800
Practice Address - Fax:505-237-8817
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM55800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90136560Medicaid