Healthcare Provider Details

I. General information

NPI: 1134490790
Provider Name (Legal Business Name): PHYLLIS DIANE MOREHEAD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHYLLIS DIANE HAWKINS RN

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 02/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH MUNDO
DULCE NM
87528-0187
US

IV. Provider business mailing address

P O BOX 187
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax:
Mailing address:
  • Phone: 575-759-7237
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1091032
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: