Basic Information
| Provider Information | |||||||||
| NPI: | 1871699769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIPLEY | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1217 BONITA | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872958 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1217 BONITA | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052872958 | ||||||||
| FaxNumber: | 5052872403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 86337 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 37960 | 05 | NM | MEDICAID |