Provider Demographics
NPI:1629417621
Name:ADANUVOR, DAVITA
Entity Type:Individual
Prefix:
First Name:DAVITA
Middle Name:
Last Name:ADANUVOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 CALLE CHAMISAL
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2976
Mailing Address - Country:US
Mailing Address - Phone:505-372-4511
Mailing Address - Fax:
Practice Address - Street 1:807 CALLE CHAMISAL
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2976
Practice Address - Country:US
Practice Address - Phone:505-372-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02206363LA2100X
WAAP61160839363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health