Provider Demographics
NPI:1063681161
Name:GWENDOLYN LEE HALL, CNM
Entity Type:Organization
Organization Name:GWENDOLYN LEE HALL, CNM
Other - Org Name:SNOWFLAKE/HEBER WOMEN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:928-535-4539
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:OVERGAARD
Mailing Address - State:AZ
Mailing Address - Zip Code:85933-0617
Mailing Address - Country:US
Mailing Address - Phone:928-535-4539
Mailing Address - Fax:928-535-4895
Practice Address - Street 1:261 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5316
Practice Address - Country:US
Practice Address - Phone:928-536-5377
Practice Address - Fax:928-536-7656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAPO244176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ490467Medicaid
AZ79846Medicare PIN
AZ490467Medicaid