Healthcare Provider Details

I. General information

NPI: 1023382355
Provider Name (Legal Business Name): JOANNA BALLARD CPM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S 19TH ST
LARAMIE WY
82070-4307
US

IV. Provider business mailing address

421 S 19TH ST
LARAMIE WY
82070
US

V. Phone/Fax

Practice location:
  • Phone: 307-256-6633
  • Fax: 303-997-1818
Mailing address:
  • Phone: 307-256-6633
  • Fax: 303-997-1818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number008
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: