Provider Demographics
NPI:1912183393
Name:LAW, VENETTA JOI (CNP)
Entity Type:Individual
Prefix:
First Name:VENETTA
Middle Name:JOI
Last Name:LAW
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 130
Mailing Address - Street 2:ATTN ACL PROVIDER ENROLLMENT
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5828
Practice Address - Street 1:6551 NE 150TH AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-5321
Practice Address - Country:US
Practice Address - Phone:443-508-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401222363LP0808X
MDR121298363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM320070Medicare Oscar/Certification