Healthcare Provider Details

I. General information

NPI: 1790373496
Provider Name (Legal Business Name): MARIAH WEST CNM, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 HARRY HINES BLVD
DALLAS TX
75235-7708
US

IV. Provider business mailing address

9012 MILL VALLEY CIR APT 191
FORT WORTH TX
76120-4817
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8000
  • Fax:
Mailing address:
  • Phone: 773-330-5625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1012879
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number1012879
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: