Provider Demographics
NPI:1760969976
Name:NATONABAH, MANDY ELIZABETH (LMT)
Entity Type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:ELIZABETH
Last Name:NATONABAH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:MANDY
Other - Middle Name:ELIZABETH
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:9 ROAD 3630
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-9620
Mailing Address - Country:US
Mailing Address - Phone:970-401-2144
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-401-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0008013225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist