Healthcare Provider Details

I. General information

NPI: 1932478955
Provider Name (Legal Business Name): SANDRA SHUYA PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2011
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5312 RIO BRAVO DR STE 10
SANTA TERESA NM
88008-9210
US

IV. Provider business mailing address

5312 RIO BRAVO DR STE 10
SANTA TERESA NM
88008-9210
US

V. Phone/Fax

Practice location:
  • Phone: 575-339-9634
  • Fax: 575-339-2789
Mailing address:
  • Phone: 915-478-8951
  • Fax: 575-339-2789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number570698
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-02567
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: