Basic Information
| Provider Information | |||||||||
| NPI: | 1992914501 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JENIFER LICHTENFELS, MD, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PEDIATRICS AFTER HOURS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1560 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880041560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056478366 | ||||||||
| FaxNumber: | 5056478381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 MISSOURI AVE | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880115075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055210630 | ||||||||
| FaxNumber: | 5055210628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERRALES | ||||||||
| AuthorizedOfficialFirstName: | KATRINA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5056478366 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 88211 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00017053 | 05 | NM | MEDICAID |