Healthcare Provider Details

I. General information

NPI: 1568180990
Provider Name (Legal Business Name): KORI DAWN STEWART LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S ATKINSON AVE
ROSWELL NM
88203-7154
US

IV. Provider business mailing address

1107 S ATKINSON AVE
ROSWELL NM
88203-7154
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-4826
  • Fax: 575-578-4828
Mailing address:
  • Phone: 575-578-4826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number66740
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: