Healthcare Provider Details

I. General information

NPI: 1255816039
Provider Name (Legal Business Name): GLENNA BELIN MARCUS LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905B CALLE ARMADA
ESPANOLA NM
87532-0000
US

IV. Provider business mailing address

PO BOX 84
OHKAY OWINGEH NM
87566-0084
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-0505
  • Fax:
Mailing address:
  • Phone: 505-221-3431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number18183R
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: