Healthcare Provider Details

I. General information

NPI: 1770248635
Provider Name (Legal Business Name): MARIAH SHATTO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH TAFOYA

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 IRVING BLVD NW
ALBUQUERQUE NM
87114-5915
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number57662
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number65401
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number57662
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: