Basic Information
Provider Information | |||||||||
NPI: | 1477715308 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LABRECHE | ||||||||
FirstName: | JULIET | ||||||||
MiddleName: | ANNE D'ANGELO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | D'ANGELO | ||||||||
OtherFirstName: | JULIET | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26666 | ||||||||
Address2: | PHS PROVIDER ENROLLMENT | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871256666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059236770 | ||||||||
FaxNumber: | 5059235354 | ||||||||
Practice Location | |||||||||
Address1: | 6100 PAN AMERICAN FREEWAY STE 450 | ||||||||
Address2: | PMG NORTHSIDE OBGYN | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871093460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5058238787 | ||||||||
FaxNumber: | 5058238788 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2008 | ||||||||
LastUpdateDate: | 04/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD2012-0219 | NM | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 390200000X | TL2869 | CO | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.