Healthcare Provider Details

I. General information

NPI: 1255040523
Provider Name (Legal Business Name): SHAUNTIANA ENRICO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 VASSAR DR NE
ALBUQUERQUE NM
87106-2725
US

IV. Provider business mailing address

PO BOX 1608
CROWNPOINT NM
87313-1608
US

V. Phone/Fax

Practice location:
  • Phone: 505-248-7730
  • Fax:
Mailing address:
  • Phone: 505-422-1248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00009804
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: