Provider Demographics
NPI:1215265137
Name:MAILLIS, NICOLE (LM, CPM)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAILLIS
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5540 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6122
Mailing Address - Country:US
Mailing Address - Phone:575-751-4690
Mailing Address - Fax:575-751-4690
Practice Address - Street 1:5540 NDCBU
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6122
Practice Address - Country:US
Practice Address - Phone:575-751-4690
Practice Address - Fax:575-751-4690
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM09060R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife