Welcome to the ACNM online membership application.
Prefix: First Name: Middle Initial: Last Name: Credentials:
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Work Phone Number: ###-###-####
Home Number: ###-###-####
Cell Number: ###-###-####
Fax Number: ###-###-####
Email: *
Organization:
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1.
Additional Credentials (check all that apply)
FNP CNS CPM
FNP (Board Certified) IBCLC LCCE
Licensed Midwife NP - Other PA
WHNP WHNP (Board Certified)
Area of Expertise
Professional liability Productivity/RVUs Billing and Coding
Precepting Primary Care Practice Locum Tenens
Ultrasound Training Colposcopy Training Experience in public speaking
Other Area of Expertise Experience in Global Health Interest in Global Health
Research: Midwifery Research: Non-Midwifery
Expanded Practices
Cervical Cryotherapy/Cryosurgery Circumcision/Dorsal Penile Nerve Block Colposcopy
Dilatation and Curettage Endometrial Biopsy/Curettage External Version
First Assisting for Cesarean Birth First Assisting for Gynecologic/Other Nexplanon Insertion/Removal
Loop Electrosurgical Excision Procedur Limited Obstetric Ultrasound Low Forcep Extraction
Manual Vacuum Aspiration Nitrous Oxide Initiation for Pain Reli Pessary Insertion/Removal
Repair of 3rd & 4th Degree Lacerations Urinary Incontinence Biofeedback/Urody Vacuum Assisted Vaginal Birth
Other Expanded Practice
I practice/practiced in an IHS or Tribal health setting:
Category:
Primary State Affiliate:
Secondary State Affiliate:
Payment Frequency: Note: There is an annual $25.00 fee for choosing monthly payments.
Purchase a year of Obstetrics & Gynecology (domestic) - $90.00