1497844732 NPI number — MRS. SHANNON MARIE STEVENS M. S. P. T.

Table of content: GREG BRAKE (NPI 1740298421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497844732 NPI number — MRS. SHANNON MARIE STEVENS M. S. P. T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEVENS
Provider First Name:
SHANNON
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M. S. P. T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497844732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
722 E FLORIDA ST/PO BX1518
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88030-5310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-546-2555
Provider Business Mailing Address Fax Number:
505-546-2725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
722 E FLORIDA ST/PO BX1518
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88030-5310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-546-2555
Provider Business Practice Location Address Fax Number:
505-546-2725
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2570 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23693 . This is a "LOVELACE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 73559 . This is a "PRESBYTERIAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM01Q136 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 57831271 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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