Healthcare Provider Details

I. General information

NPI: 1558343111
Provider Name (Legal Business Name): MARY CLAIRE WAHL C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5063
  • Fax:
Mailing address:
  • Phone: 719-333-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: