Provider Demographics
NPI:1376116954
Name:NOURSE, SHYANNE ATOCHA (LSAA)
Entity Type:Individual
Prefix:
First Name:SHYANNE
Middle Name:ATOCHA
Last Name:NOURSE
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HY PEAR LOOP
Mailing Address - Street 2:
Mailing Address - City:PERALTA
Mailing Address - State:NM
Mailing Address - Zip Code:87042-8413
Mailing Address - Country:US
Mailing Address - Phone:505-917-3844
Mailing Address - Fax:
Practice Address - Street 1:630 HAINES AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1226
Practice Address - Country:US
Practice Address - Phone:505-917-3844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0218821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCSA0218821OtherLSAA