Healthcare Provider Details

I. General information

NPI: 1831985472
Provider Name (Legal Business Name): KEZIA ELIZABETH TATHAM CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 LAS ESTANCIAS DR SW OBSTETRICS AND GYNECOLOGY
ALBUQUERQUE NM
87121-5504
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-7777
  • Fax: 505-462-7726
Mailing address:
  • Phone: 917-530-3041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number915
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: