Healthcare Provider Details

I. General information

NPI: 1811921943
Provider Name (Legal Business Name): MARY MAGDALENA COLTON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY MAGDALENA WEINER

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E. NIZHONI BLVD. BOX 1337
GALLUP NM
87301-1337
US

IV. Provider business mailing address

516 E. NIZHONI BLVD. BOX 1337
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1268
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR44205
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number444
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: