Healthcare Provider Details

I. General information

NPI: 1134575962
Provider Name (Legal Business Name): ELIZABETH HARTSHORN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HOLGUIN RD
VADO NM
88072-7220
US

IV. Provider business mailing address

330 HOLGUIN RD
VADO NM
88072-7220
US

V. Phone/Fax

Practice location:
  • Phone: 575-233-5004
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR42575
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: