Provider Demographics
NPI:1467207084
Name:LISTER, TANYA (CNM)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LISTER
Suffix:
Gender:
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:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87416-1106
Mailing Address - Country:US
Mailing Address - Phone:505-330-1413
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 160
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-0160
Practice Address - Country:US
Practice Address - Phone:505-368-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM895367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife