Provider Demographics
NPI:1013677350
Name:BACA-HUMMELL, LISA MICHELLE (MSN, RN, FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:BACA-HUMMELL
Suffix:
Gender:F
Credentials:MSN, RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2437 CUTLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2507
Mailing Address - Country:US
Mailing Address - Phone:505-379-0311
Mailing Address - Fax:
Practice Address - Street 1:2437 CUTLER AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2507
Practice Address - Country:US
Practice Address - Phone:505-379-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM09211462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09211462OtherNM BOARD OF NURSING, FAMILY NURSE PRACTITIONER LICENSE