Provider Demographics
NPI:1134490790
Name:MOREHEAD, PHYLLIS DIANE (RN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:DIANE
Last Name:MOREHEAD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:DIANE
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:P O BOX 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-7237
Mailing Address - Fax:575-759-7294
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1091032163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B