Provider Demographics
NPI:1922314541
Name:ESPANOLA VALLEY WOMENS HEALTH
Entity Type:Organization
Organization Name:ESPANOLA VALLEY WOMENS HEALTH
Other - Org Name:ESPANOLA MIDWIFERY SERVICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRECHETTE-GUTFREUND
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:505-508-7209
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0157
Mailing Address - Country:US
Mailing Address - Phone:505-508-7209
Mailing Address - Fax:
Practice Address - Street 1:705 LA JOYA ST STE A
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2233
Practice Address - Country:US
Practice Address - Phone:505-508-7209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM09065R175M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175M00000XOther Service ProvidersMidwife, LayGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56859023Medicaid