Healthcare Provider Details

I. General information

NPI: 1972350692
Provider Name (Legal Business Name): MARISSA EVARTS LICE MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87104-3224
US

IV. Provider business mailing address

2002 FIVE POINTS RD SW
ALBUQUERQUE NM
87105-3042
US

V. Phone/Fax

Practice location:
  • Phone: 505-375-1397
  • Fax: 505-431-4774
Mailing address:
  • Phone: 412-328-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number23006R
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: