Healthcare Provider Details

I. General information

NPI: 1972087054
Provider Name (Legal Business Name): CHANGING WOMAN INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-6741
US

IV. Provider business mailing address

4133 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-6741
US

V. Phone/Fax

Practice location:
  • Phone: 505-660-6372
  • Fax: 505-393-5165
Mailing address:
  • Phone: 505-660-6372
  • Fax: 505-393-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: NICOLLE GONZALES
Title or Position: EXECUTIVE DIRECTOR/FOUNDER
Credential: CNM
Phone: 505-954-1546