Provider Demographics
NPI:1871838078
Name:OTERO-GRANGER, REBECCA ANNE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:OTERO-GRANGER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 N MESA RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-8528
Mailing Address - Country:US
Mailing Address - Phone:505-350-1035
Mailing Address - Fax:505-200-2695
Practice Address - Street 1:111 ISLETA BLVD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3896
Practice Address - Country:US
Practice Address - Phone:505-200-2647
Practice Address - Fax:505-200-2695
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02087364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health