Basic Information
Provider Information | |||||||||
NPI: | 1487283040 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHANKS | ||||||||
FirstName: | KRISTEN | ||||||||
MiddleName: | JOY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GALBREATH | ||||||||
OtherFirstName: | KRISTEN | ||||||||
OtherMiddleName: | JOY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6210 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874996210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5056092258 | ||||||||
FaxNumber: | 5056092259 | ||||||||
Practice Location | |||||||||
Address1: | 655 W PINON ST | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | NM | ||||||||
PostalCode: | 874015973 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5056092590 | ||||||||
FaxNumber: | 5056092595 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2020 | ||||||||
LastUpdateDate: | 11/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X |   |   | Y |   | Other Service Providers | Midwife |   |
No ID Information.