Basic Information
| Provider Information | |||||||||
| NPI: | 1326362278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALLANTINE | ||||||||
| FirstName: | CHARLOTTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | MSC10 5550 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724661 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871319654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206926068 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 390200000X | NM | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.