Healthcare Provider Details

I. General information

NPI: 1487624474
Provider Name (Legal Business Name): MARILYN D MILLER-SHULTZ CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN D MILLER SHULTZ CNP

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N DATE ST
T OR C NM
87901-3701
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-7662
  • Fax:
Mailing address:
  • Phone: 575-266-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP00485
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: