Provider Demographics
NPI:1619731668
Name:GOLDBERG, MELANIE A (CNM)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:GOLDBERG
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 1:4705 MONTGOMERY BLVD NE STE 301
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1234
Mailing Address - Country:US
Mailing Address - Phone:505-727-4500
Mailing Address - Fax:
Practice Address - Street 1:4705 MONTGOMERY BLVD NE STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1234
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNM08859207V00000X
NM871367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM871OtherCNM LICENSE # 871