Healthcare Provider Details

I. General information

NPI: 1255347043
Provider Name (Legal Business Name): GAYLIA DIANNE PRIDE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE RD
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 752
CHAMA NM
87520-0752
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-7248
  • Fax: 505-759-7294
Mailing address:
  • Phone: 505-756-1598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberR47562
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: