Provider Demographics
NPI:1245780626
Name:MENK, SHELLEY ELIZABETH (DPT)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:ELIZABETH
Last Name:MENK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 MIRAVISTA PL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-6001
Mailing Address - Country:US
Mailing Address - Phone:505-490-1788
Mailing Address - Fax:
Practice Address - Street 1:407 19TH ST NW APT 3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-1556
Practice Address - Country:US
Practice Address - Phone:505-490-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0862225200000X
NMPT5320225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM03-362564-00-6OtherNEW MEXICO TAXATION AND REVENUE DEPARTMENT BUSINESS REGISTRATION CERTIFICATE
NMA-0862OtherNEW MEXICO PHYSICAL THERAPY BOARD LICENSE