Provider Demographics
NPI:1487624474
Name:MILLER-SHULTZ, MARILYN D (CNP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:D
Last Name:MILLER-SHULTZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MARILYN D
Other - Middle Name:MILLER
Other - Last Name:SHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-266-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1960 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-3701
Practice Address - Country:US
Practice Address - Phone:575-894-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00485363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR25875OtherAPN STATE LICENSURE
P86556Medicare UPIN
344314101Medicare ID - Type Unspecified