Provider Demographics
NPI:1134850779
Name:CHAMPOUILLON, ROBERTA (NP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:CHAMPOUILLON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 CENTRAL AVE NE APT 3005
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1961
Mailing Address - Country:US
Mailing Address - Phone:423-483-4310
Mailing Address - Fax:
Practice Address - Street 1:5310 HOMESTEAD RD NE BLDG 4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1524
Practice Address - Country:US
Practice Address - Phone:505-256-3648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM68592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily