Provider Demographics
NPI:1730169699
Name:VERGARA-BLAKE, JUDITH M (CNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:VERGARA-BLAKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:M
Other - Last Name:HARDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1500 WALTER ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4658
Practice Address - Country:US
Practice Address - Phone:505-272-1393
Practice Address - Fax:505-272-2177
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR51480163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75502330Medicaid