Healthcare Provider Details

I. General information

NPI: 1023236536
Provider Name (Legal Business Name): STACI ELIZABETH OLDHAM NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2007
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 TENTH STREET
MAGDALENA NM
87825
US

IV. Provider business mailing address

801 TENTH STREET
MAGDALENA NM
87825
US

V. Phone/Fax

Practice location:
  • Phone: 575-854-3162
  • Fax:
Mailing address:
  • Phone: 575-854-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number527845
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP01459
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: