Provider Demographics
NPI:1730930611
Name:CAUDILL, SHALA MARIE
Entity type:Individual
Prefix:
First Name:SHALA
Middle Name:MARIE
Last Name:CAUDILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHALA
Other - Middle Name:MARIE
Other - Last Name:RITCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2421 W 21ST ST STE B
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2006
Mailing Address - Country:US
Mailing Address - Phone:620-259-0903
Mailing Address - Fax:
Practice Address - Street 1:2421 W 21ST ST STE B
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-2006
Practice Address - Country:US
Practice Address - Phone:620-259-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM78291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty