Provider Demographics
NPI:1295707651
Name:LIESVELD, JUDY (CNP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:LIESVELD
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 1:1901 REDROCK DR
Mailing Address - Street 2:REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-863-1820
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR30234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99628Medicaid
NMPROVP14473OtherMOLINA
NM10002112OtherLOVELACE HEALTH/SALUD
85031326887301A120OtherCHAMPUS
AZ469066Medicaid
NMNM006180OtherBC/BS
NMNM006180OtherBC/BS