Basic Information
Provider Information | |||||||||
NPI: | 1629185020 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SAMPLE | ||||||||
FirstName: | MARIE | ||||||||
MiddleName: | MARGUERITE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18 IMPERIAL PL UNIT 2D | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029034642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017274800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 18 IMPERIAL PL UNIT 2D | ||||||||
Address2: |   | ||||||||
City: | PROVIDENCE | ||||||||
State: | RI | ||||||||
PostalCode: | 029034642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017274800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 11/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 11987 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   | 367A00000X | CNM00178 | RI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 726695410A | 05 | GA |   | MEDICAID | 582369659 | 01 | GA | PRIVATE INS COMPANIES | OTHER |