Healthcare Provider Details

I. General information

NPI: 1275952608
Provider Name (Legal Business Name): HIGH DESERT MIDWIFERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

IV. Provider business mailing address

4916 4TH ST NW
ALBUQUERQUE NM
87107-3949
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-2222
  • Fax: 877-500-7949
Mailing address:
  • Phone: 505-450-2222
  • Fax: 877-500-7949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number1412R
License Number StateNM

VIII. Authorized Official

Name: LOUISE SELF
Title or Position: MIDWIFE
Credential: LM, CPM
Phone: 505-450-2222