Provider Demographics
NPI:1083869044
Name:ISHAM, ELEONORE
Entity Type:Individual
Prefix:
First Name:ELEONORE
Middle Name:
Last Name:ISHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 SHEFFIELD DR STE F
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4946
Mailing Address - Country:US
Mailing Address - Phone:575-762-2660
Mailing Address - Fax:
Practice Address - Street 1:1800 SHEFFIELD DR STE F
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4946
Practice Address - Country:US
Practice Address - Phone:575-762-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMT 6158175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath