Provider Demographics
NPI:1629172333
Name:VENTURA, VICKI (MSN,CNS,APRN,BC)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:
Last Name:VENTURA
Suffix:
Gender:F
Credentials:MSN,CNS,APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4608 GRETTA COURT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3715
Mailing Address - Country:US
Mailing Address - Phone:505-452-2286
Mailing Address - Fax:
Practice Address - Street 1:4801 LANG AVENUE NE
Practice Address - Street 2:SUITE 110
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4407
Practice Address - Country:US
Practice Address - Phone:505-798-2633
Practice Address - Fax:505-796-9801
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNS0069364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93183038Medicaid