Healthcare Provider Details

I. General information

NPI: 1003662768
Provider Name (Legal Business Name): SHELBY DANAE WHITLOCK-VIRDEN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELBY WHITLOCK

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 MEADOW CIR
LAS CRUCES NM
88007-5616
US

IV. Provider business mailing address

5020 MEADOW CIR
LAS CRUCES NM
88007-5616
US

V. Phone/Fax

Practice location:
  • Phone: 575-649-7113
  • Fax:
Mailing address:
  • Phone: 575-649-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number77549
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: