Provider Demographics
NPI:1528010279
Name:HARRIS, SHARON B (RD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:B
Last Name:HARRIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9347
Mailing Address - Country:US
Mailing Address - Phone:575-356-6652
Mailing Address - Fax:575-226-0099
Practice Address - Street 1:42121 US HWY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9347
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:575-226-0099
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM072133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH5509Medicaid
NM000H5509Medicaid
343617901Medicare PIN
NM302545Medicare PIN