Provider Demographics
NPI:1285327627
Name:FASSLER-WARDLAW, JAMIE (RN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:FASSLER-WARDLAW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:FASSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2505 MESA CROTALO RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8955
Mailing Address - Country:US
Mailing Address - Phone:505-506-4912
Mailing Address - Fax:
Practice Address - Street 1:5901 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3073
Practice Address - Country:US
Practice Address - Phone:505-910-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-86959163WP0809X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult