Healthcare Provider Details

I. General information

NPI: 1871209668
Provider Name (Legal Business Name): MIKO REANN BIRDSONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 IMPERIAL CT
CLOVIS NM
88101-8633
US

IV. Provider business mailing address

1725 IMPERIAL CT
CLOVIS NM
88101-8633
US

V. Phone/Fax

Practice location:
  • Phone: 575-219-2505
  • Fax:
Mailing address:
  • Phone: 575-219-2505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2022-1021
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: