Healthcare Provider Details

I. General information

NPI: 1306002183
Provider Name (Legal Business Name): CORTNEY DAWN MINER PREATOR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CORTNEY DAWN MARSHALL RN

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N BERGIN LN
BLOOMFIELD NM
87413-6729
US

IV. Provider business mailing address

325 N BERGIN LN
BLOOMFIELD NM
87413-6729
US

V. Phone/Fax

Practice location:
  • Phone: 505-634-3673
  • Fax: 505-634-3675
Mailing address:
  • Phone: 505-634-2121
  • Fax: 505-634-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number850
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number74947
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: