Provider Demographics
NPI:1114908761
Name:KNACKSTEDT, SHIRLEY (CFNP)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:KNACKSTEDT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7218 4TH ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6624
Mailing Address - Country:US
Mailing Address - Phone:505-730-5603
Mailing Address - Fax:505-554-2313
Practice Address - Street 1:7218 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6624
Practice Address - Country:US
Practice Address - Phone:505-730-5603
Practice Address - Fax:505-554-2313
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR39671/CNP00873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK3771Medicaid
NMK3771Medicaid