Healthcare Provider Details

I. General information

NPI: 1790754737
Provider Name (Legal Business Name): LISA L MATTKE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE. 5640
ALBUQUERQUE NM
87106-4917
US

IV. Provider business mailing address

201 CEDAR ST SE STE. 5640
ALBUQUERQUE NM
87106-4917
US

V. Phone/Fax

Practice location:
  • Phone: 505-843-6168
  • Fax: 505-247-9743
Mailing address:
  • Phone: 505-843-6168
  • Fax: 505-247-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberR148101-3
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number620
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: