Provider Demographics
NPI:1932701372
Name:DEAN, MICHELLE (CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9345
Mailing Address - Country:US
Mailing Address - Phone:505-264-2352
Mailing Address - Fax:
Practice Address - Street 1:1302 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2508
Practice Address - Country:US
Practice Address - Phone:575-461-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM60358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily