Provider Demographics
NPI:1003192956
Name:DESERT SKIES FAMILY PRACTICE INC.
Entity Type:Organization
Organization Name:DESERT SKIES FAMILY PRACTICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ILANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:575-437-1113
Mailing Address - Street 1:1101 9TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6432
Mailing Address - Country:US
Mailing Address - Phone:575-437-1113
Mailing Address - Fax:575-437-1777
Practice Address - Street 1:1101 9TH ST STE B
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6432
Practice Address - Country:US
Practice Address - Phone:575-437-1113
Practice Address - Fax:575-437-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR21461261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1427011881OtherNPI TYPE I
NM89009851Medicaid
NMNM AAA2448OtherMEDICARE # I RECEIVED
NM89009851Medicaid