Provider Demographics
NPI:1598435414
Name:TATUM, SHELBY J'AUN
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:J'AUN
Last Name:TATUM
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:PO BOX 673
Mailing Address - Street 2:
Mailing Address - City:HOUSE
Mailing Address - State:NM
Mailing Address - Zip Code:88121-0673
Mailing Address - Country:US
Mailing Address - Phone:575-279-7353
Mailing Address - Fax:575-279-6133
Practice Address - Street 1:309 APPLE STREET
Practice Address - Street 2:
Practice Address - City:HOUSE
Practice Address - State:NM
Practice Address - Zip Code:88121
Practice Address - Country:US
Practice Address - Phone:575-279-7353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77902163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool