Provider Demographics
NPI:1881892271
Name:STACK, ELAINE BECKER (ANP-BC,ACNP-BC, CCNS)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:BECKER
Last Name:STACK
Suffix:
Gender:F
Credentials:ANP-BC,ACNP-BC, CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:BUILDING 4 SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-272-2273
Practice Address - Fax:505-272-2075
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR60088363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health