Basic Information
| Provider Information | |||||||||
| NPI: | 1134298854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLTONUK | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOLTONUK | ||||||||
| OtherFirstName: | JAN | ||||||||
| OtherMiddleName: | LYN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LISW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4316 CARLISLE BLVD NE | ||||||||
| Address2: | STE D | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Practice Location | |||||||||
| Address1: | 4316 CARLISLE BLVD NE | ||||||||
| Address2: | STE D | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058372100 | ||||||||
| FaxNumber: | 5058887943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I3882 | NM | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.