Individual
JUDY LIESVELD
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
CNP
Contact information
Practice address
2111 COLLEGE DR, REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES, GALLUP, NM 87301-5600
(505) 863-1820
Mailing address
1901 REDROCK DR, REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES, GALLUP, NM 87301-5683
(505) 863-7000
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
R30234
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10002112
LOVELACE HEALTH/SALUD
NM
05
—
469066
—
AZ
01
—
85031326887301A120
CHAMPUS
—
05
—
99628
—
NM
01
—
NM006180
BC/BS
NM
01
—
PROVP14473
MOLINA
NM
Enumeration date
02/01/2006
Last updated
07/09/2007
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