Healthcare Provider Details

I. General information

NPI: 1740956374
Provider Name (Legal Business Name): KRISTEN MCLIVERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 64 OLD HIGH SCHOOL RD US HWY 64 OLD HIGH SCHOOL RD
SHIPROCK NM
87420-8742
US

IV. Provider business mailing address

PO BOX 1199
SHIPROCK NM
87420-1199
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-5163
  • Fax: 505-368-5502
Mailing address:
  • Phone: 505-368-5163
  • Fax: 505-368-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR37400
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: