Provider Demographics
NPI:1932509403
Name:FUNCTIONAL FAMILY MEDICINE
Entity Type:Organization
Organization Name:FUNCTIONAL FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-550-1183
Mailing Address - Street 1:7301 JEFFERSON ST NE STE G
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4363
Mailing Address - Country:US
Mailing Address - Phone:505-225-4044
Mailing Address - Fax:505-508-5284
Practice Address - Street 1:7301 JEFFERSON ST NE STE G
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4363
Practice Address - Country:US
Practice Address - Phone:505-225-4044
Practice Address - Fax:505-508-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty