Provider Demographics
NPI:1528447810
Name:JUSTICE, MEREDITH PHIPPS (PNP)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:PHIPPS
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:INGRID
Other - Last Name:PHIPPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:407 S SCHWARTZ AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5925
Mailing Address - Country:US
Mailing Address - Phone:505-609-6700
Mailing Address - Fax:505-599-4634
Practice Address - Street 1:407 S SCHWARTZ AVE STE 102
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-609-6700
Practice Address - Fax:505-599-4634
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127925363LP0200X
NM54473208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty