Healthcare Provider Details

I. General information

NPI: 1477429611
Provider Name (Legal Business Name): SHANDINA MANYCOWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RIO VISTA ESTATES LOT #24
SANDERS AZ
86512
US

IV. Provider business mailing address

947 CERRITO DR
GALLUP NM
87301-5421
US

V. Phone/Fax

Practice location:
  • Phone: 928-688-3903
  • Fax: 928-688-4471
Mailing address:
  • Phone: 928-688-3903
  • Fax: 928-688-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343048
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: