Healthcare Provider Details

I. General information

NPI: 1992057491
Provider Name (Legal Business Name): HANNAH BOOMER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HANNAH RENZI CNM

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW 5TH ST
REDMOND OR
97756-1869
US

IV. Provider business mailing address

PO BOX 5579
BEND OR
97708-5579
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-6635
  • Fax: 541-526-6636
Mailing address:
  • Phone: 541-706-5920
  • Fax: 541-706-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP60306575
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number201404953NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: