Healthcare Provider Details

I. General information

NPI: 1760571913
Provider Name (Legal Business Name): TANJA BOLLE LM,CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

968 ALTO ST
SANTA FE NM
87501-2405
US

IV. Provider business mailing address

968 ALTO ST
SANTA FE NM
87501-2405
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-7104
  • Fax:
Mailing address:
  • Phone: 505-992-7104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number95284R
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: