Provider Demographics
NPI:1295700912
Name:CHURCH, ANN K (MD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:K
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2115
Mailing Address - Country:US
Mailing Address - Phone:505-287-6500
Mailing Address - Fax:
Practice Address - Street 1:833 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2115
Practice Address - Country:US
Practice Address - Phone:505-287-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036151567207V00000X
NMNM2010-0079207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
905524OtherABOG
NMNM2010-0079OtherMEDICAL LICENSE
NMNM2010-0079OtherMEDICAL LICENSE
905524OtherABOG