Provider Demographics
NPI:1902200181
Name:KING, MINDY
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:KING
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 1:2600 YALE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4217
Mailing Address - Country:US
Mailing Address - Phone:505-980-4293
Mailing Address - Fax:505-994-7975
Practice Address - Street 1:2600 YALE BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4217
Practice Address - Country:US
Practice Address - Phone:505-980-4293
Practice Address - Fax:505-994-7975
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-16
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN 80051163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)