Healthcare Provider Details

I. General information

NPI: 1124609979
Provider Name (Legal Business Name): SHAY MALYNN BENNER CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 05/26/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

933 BRADBURY DR SE STE 2222
ALBUQUERQUE NM
87106-4375
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5551
  • Fax: 272-684-5505
Mailing address:
  • Phone: 505-272-5551
  • Fax: 505-272-6845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number62095
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: