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General NPI Number Information
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NPI Number | 1003192956
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Entity Type | Organization
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Legal Business Name | DESERT SKIES FAMILY PRACTICE INC.
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Dates
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Enumeration Date | 10/24/2011
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Last Update Date | 03/26/2012
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Provider Practice Location Address
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Address Line | 1101 9TH ST STE B
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City | ALAMOGORDO
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State | NM
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Zip | 88310-6432
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Country | US
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Telephone | 575-437-1113
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Fax | 575-437-1777
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Provider Business Mailing Address
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Address Line | 1101 9TH ST STE B
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City | ALAMOGORDO
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State | NM
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Zip | 88310-6432
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Country | US
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Telephone | 575-437-1113
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Fax | 575-437-1777
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | ILANA CORNELIUS
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Credential | CNP
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Telephone | 575-437-1113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | R21461
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License Number State | NM
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