Healthcare Provider Details

I. General information

NPI: 1912725300
Provider Name (Legal Business Name): KIMBERLY IONE WAGELEY WHNP/CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4934
US

IV. Provider business mailing address

9505 THUNDER RD NW
ALBUQUERQUE NM
87120-4233
US

V. Phone/Fax

Practice location:
  • Phone: 505-907-8375
  • Fax:
Mailing address:
  • Phone: 505-907-8375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number887
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: