Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | CNP01279 | NM |
N | 363L00000X | Nurse Practitioner | R53026 | NM |
NPI | 1003809708 |
---|---|
Provider Name | Cheryl Granillo |
First Address | Hatch, NM 87937-0370 |
Second Address | Deming, NM 88030-8629 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2005 |
Last Update Date | 01/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
53985788 | (05) | NM |
Q26715 | (02) |