Provider Demographics
NPI:1669885182
Name:BOYLAN, KATIE (FNP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BOYLAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 JEFFERSON ST NE
Mailing Address - Street 2:STE 340
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4494
Mailing Address - Country:US
Mailing Address - Phone:505-338-3851
Mailing Address - Fax:
Practice Address - Street 1:111 RIO RANCHO BLVD SE
Practice Address - Street 2:STE 108
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-7020
Practice Address - Country:US
Practice Address - Phone:505-892-8117
Practice Address - Fax:505-892-8515
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMCNP-02459363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program