Provider Demographics
NPI:1053670612
Name:LAVENDER AND LACE BIRTH & WOMENS HEALTH SERVICES PLLC
Entity Type:Organization
Organization Name:LAVENDER AND LACE BIRTH & WOMENS HEALTH SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CNM
Authorized Official - Phone:409-789-8258
Mailing Address - Street 1:1204 GARNER ST
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4278
Mailing Address - Country:US
Mailing Address - Phone:409-789-8258
Mailing Address - Fax:
Practice Address - Street 1:310 JACOB STREET
Practice Address - Street 2:
Practice Address - City:TIMPSON
Practice Address - State:TX
Practice Address - Zip Code:75975-5028
Practice Address - Country:US
Practice Address - Phone:936-254-3338
Practice Address - Fax:936-254-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251633176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307575601Medicaid
TX1053670612OtherTYPE II NPI
TX307575601Medicaid