Provider Demographics
NPI:1326170317
Name:GWENDOLYN LEE HALL CNM INC
Entity Type:Organization
Organization Name:GWENDOLYN LEE HALL CNM INC
Other - Org Name:SNOWFLAKE HEBER WOMEN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
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 2:2947 HWY 260
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:928-536-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP0244261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ490467Medicaid
AZ79846Medicare PIN
AZS93017Medicare UPIN