Healthcare Provider Details

I. General information

NPI: 1467207084
Provider Name (Legal Business Name): TANYA LISTER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2024
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 160
SHIPROCK NM
87420-0160
US

IV. Provider business mailing address

PO BOX 1106
FRUITLAND NM
87416-1106
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6900
  • Fax:
Mailing address:
  • Phone: 505-330-1413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number895
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: