Provider Demographics
NPI:1578863627
Name:DERRY, ELIZABETH MARY (CPM,LM)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARY
Last Name:DERRY
Suffix:
Gender:F
Credentials:CPM,LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 HALL DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-1121
Mailing Address - Country:US
Mailing Address - Phone:575-322-4432
Mailing Address - Fax:888-810-9658
Practice Address - Street 1:902 HALL DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-1121
Practice Address - Country:US
Practice Address - Phone:575-322-4432
Practice Address - Fax:888-810-9658
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99110176B00000X
NM16156R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife