Healthcare Provider Details

I. General information

NPI: 1295055036
Provider Name (Legal Business Name): TREE OF LIFE MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2224 LAS BRISAS CT SE
RIO RANCHO NM
87124
US

IV. Provider business mailing address

2224 LAS BRISAS CT SE
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-6890
  • Fax:
Mailing address:
  • Phone: 505-796-6890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number09063R
License Number StateNM

VIII. Authorized Official

Name: MS. JULIE A JOHNSTUN
Title or Position: OWNER
Credential: LM, CPM, LDEM
Phone: 505-504-4519