Healthcare Provider Details

I. General information

NPI: 1841529013
Provider Name (Legal Business Name): SHERRY RENEA WALL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 GOAT SPRING ROAD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 1946
TAOS NM
87571-1946
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4224
  • Fax: 575-751-5210
Mailing address:
  • Phone: 575-758-4224
  • Fax: 575-751-5210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN173987
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: