Provider Demographics
NPI:1780799452
Name:VIGNE, LAURIE L (RN, CDE)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:VIGNE
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:L
Other - Last Name:YELVINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CDE
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:1010 SPRUCE ST
Practice Address - Street 2:ESPANOLA MULTI-SPECIALTY CLINIC
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2724
Practice Address - Country:US
Practice Address - Phone:505-753-8031
Practice Address - Fax:505-753-7433
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR27926132700000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMedicare ID - Type Unspecified