Healthcare Provider Details

I. General information

NPI: 1891192571
Provider Name (Legal Business Name): REBEKAH BLYTHE C.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 E 2ND AVE STE 4/5
DURANGO CO
81301-5563
US

IV. Provider business mailing address

57 COUNTY ROAD 515
IGNACIO CO
81137-8709
US

V. Phone/Fax

Practice location:
  • Phone: 970-749-4497
  • Fax:
Mailing address:
  • Phone: 970-749-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberM.W.R.0000159
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number14130R
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: