Provider Demographics
NPI:1417568676
Name:BLACKWELL MILLER, SHANE RENEE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:RENEE
Last Name:BLACKWELL MILLER
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 1:516 E NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5748
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:
Practice Address - Street 1:933 GARRETT DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-1420
Practice Address - Country:US
Practice Address - Phone:205-746-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-80007163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse