Provider Demographics
NPI:1174047187
Name:PFANNENSTIEL, MARYLEE ROSE (RN)
Entity type:Individual
Prefix:
First Name:MARYLEE
Middle Name:ROSE
Last Name:PFANNENSTIEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1199
Mailing Address - Country:US
Mailing Address - Phone:505-368-5163
Mailing Address - Fax:505-368-5502
Practice Address - Street 1:US HWY 64 OLD HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-1199
Practice Address - Country:US
Practice Address - Phone:505-368-5163
Practice Address - Fax:505-368-5502
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-69686163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMJ7695Medicaid