Provider Demographics
NPI:1104608322
Name:SALAZAR, SANDRA GAYLE (PMHNP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:GAYLE
Last Name:SALAZAR
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CAMILLO RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-5716
Mailing Address - Country:US
Mailing Address - Phone:505-350-5945
Mailing Address - Fax:
Practice Address - Street 1:4425 JUAN TABO BLVD NE STE 112
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2684
Practice Address - Country:US
Practice Address - Phone:505-503-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM75454363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health