Healthcare Provider Details

I. General information

NPI: 1790779007
Provider Name (Legal Business Name): SHELLEY P SCHOONOVER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD STE 128
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

3917 WEST RD STE 128
LOS ALAMOS NM
87544-2275
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-4234
  • Fax: 505-662-7894
Mailing address:
  • Phone: 505-662-4234
  • Fax: 505-662-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number93385
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ0249
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: