Healthcare Provider Details

I. General information

NPI: 1649891359
Provider Name (Legal Business Name): SARAH ELIZABETH KANKIEWICZ CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 E JENSEN ST UNIT 162
MESA AZ
85203-2594
US

IV. Provider business mailing address

630 E JENSEN ST UNIT 162
MESA AZ
85203-2594
US

V. Phone/Fax

Practice location:
  • Phone: 480-788-4404
  • Fax:
Mailing address:
  • Phone: 480-788-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM230
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19120001
Identifier TypeOTHER
Identifier State
Identifier IssuerNORTH AMERICAN REGISTRY OF MIDWIVES
# 2
IdentifierLM230
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerARIZONA DEPARTMENT OF HEALTH SERVICES LICENCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: