Healthcare Provider Details

I. General information

NPI: 1407846801
Provider Name (Legal Business Name): MARY LEANORA MALLERNEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 N
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6401
  • Fax: 505-368-6431
Mailing address:
  • Phone: 505-368-6401
  • Fax: 505-368-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR49684
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR49684
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: