Healthcare Provider Details

I. General information

NPI: 1013823483
Provider Name (Legal Business Name): STACEY GARRETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 64 OLD HIGH SCHOOL RD
SHIPROCK NM
87420
US

IV. Provider business mailing address

24 ROAD 6763
FRUITLAND NM
87416-8101
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-4984
  • Fax:
Mailing address:
  • Phone: 505-920-3919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number62517
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: