Provider Demographics
NPI:1053657775
Name:EARTHEN VESSELS NURSE MIDWIFERY LLC
Entity Type:Organization
Organization Name:EARTHEN VESSELS NURSE MIDWIFERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE MIDWIFE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHRISSIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:260-704-7166
Mailing Address - Street 1:1755 COUNTY ROAD 36
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-9404
Mailing Address - Country:US
Mailing Address - Phone:260-704-7166
Mailing Address - Fax:260-357-0282
Practice Address - Street 1:251 AIRPORT NORTH OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-6702
Practice Address - Country:US
Practice Address - Phone:260-704-7166
Practice Address - Fax:260-357-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000220A261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty