Provider Demographics
NPI:1982825667
Name:NANULIA
Entity Type:Organization
Organization Name:NANULIA
Other - Org Name:PASSPORT HEALTH NEW MEXICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCI
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-881-8785
Mailing Address - Street 1:1717 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4058
Mailing Address - Country:US
Mailing Address - Phone:505-881-8785
Mailing Address - Fax:
Practice Address - Street 1:1717 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE 212
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7001
Practice Address - Country:US
Practice Address - Phone:505-881-8785
Practice Address - Fax:505-872-8785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03-035189-008261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine