Provider Demographics
NPI:1083754634
Name:TRILLIUM WOMANCARE LLC
Entity Type:Organization
Organization Name:TRILLIUM WOMANCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:STEWART-BANBURY
Authorized Official - Suffix:
Authorized Official - Credentials:CPM-TN
Authorized Official - Phone:901-292-5354
Mailing Address - Street 1:2610 AUTUMN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112
Mailing Address - Country:US
Mailing Address - Phone:901-292-5354
Mailing Address - Fax:901-452-8088
Practice Address - Street 1:2610 AUTUMN AVENUE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112
Practice Address - Country:US
Practice Address - Phone:901-292-5354
Practice Address - Fax:901-452-8088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCPM0000000030.176B00000X
TNAPN 10920367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty