Provider Demographics
NPI:1487710596
Name:KOSHEWA, CONNIE L (LM, CPM)
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:L
Last Name:KOSHEWA
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 1:21 GARDEN PARK CIR NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-2655
Mailing Address - Country:US
Mailing Address - Phone:505-293-1147
Mailing Address - Fax:
Practice Address - Street 1:123 WELLESLEY DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1443
Practice Address - Country:US
Practice Address - Phone:505-266-5762
Practice Address - Fax:505-268-7500
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM04008R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97423882Medicaid