Provider Demographics
NPI:1023060142
Name:WALSH, CRISTY JANESE (CNM)
Entity type:Individual
Prefix:
First Name:CRISTY
Middle Name:JANESE
Last Name:WALSH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W 21ST ST
Mailing Address - Street 2:STE A-1
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4087
Mailing Address - Country:US
Mailing Address - Phone:575-762-8055
Mailing Address - Fax:575-763-3351
Practice Address - Street 1:42121 US HIGHWAY 70
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9054
Practice Address - Country:US
Practice Address - Phone:575-356-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM448367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39073Medicaid
545403Medicare UPIN