Healthcare Provider Details

I. General information

NPI: 1689817637
Provider Name (Legal Business Name): KIM RALEIGH PRAIRIE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL LOOP NE STE 105
ALBUQUERQUE NM
87109-2100
US

IV. Provider business mailing address

6320 RIVERSIDE PLAZA LN NW STE B
ALBUQUERQUE NM
87120-1710
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-6168
  • Fax: 505-792-1978
Mailing address:
  • Phone: 505-843-6168
  • Fax: 505-792-1978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR35843
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number578
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: