Provider Demographics
NPI:1780615302
Name:FITZGERALD, DEBRA SHERYL (NP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SHERYL
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEB
Other - Middle Name:
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1204 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3914
Mailing Address - Country:US
Mailing Address - Phone:575-838-2367
Mailing Address - Fax:575-838-4689
Practice Address - Street 1:1204 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-838-2367
Practice Address - Fax:575-838-4689
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 102455-1363L00000X, 363LP0200X
NMCNP-01634363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ39339Medicare UPIN