Healthcare Provider Details

I. General information

NPI: 1477826287
Provider Name (Legal Business Name): INDIGO MIDWIFERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12036 COPPER AVE NE
ALBUQUERQUE NM
87123-1474
US

IV. Provider business mailing address

12036 COPPER AVE NE
ALBUQUERQUE NM
87123-1474
US

V. Phone/Fax

Practice location:
  • Phone: 505-604-9458
  • Fax: 505-271-2979
Mailing address:
  • Phone: 505-604-9458
  • Fax: 505-271-2979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number10079R
License Number StateNM

VIII. Authorized Official

Name: JESSICA WEED
Title or Position: MIDWIFE
Credential: LM, CPM, CD(DONA)
Phone: 505-604-9458