Provider Demographics
NPI:1255505525
Name:COUNTRY MIDWIFE LLC
Entity Type:Organization
Organization Name:COUNTRY MIDWIFE LLC
Other - Org Name:COUNTRY MIDWIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MIDWIFE, MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANDENPUT
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:920-562-9058
Mailing Address - Street 1:1638 DECKNER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-2640
Mailing Address - Country:US
Mailing Address - Phone:920-562-9058
Mailing Address - Fax:
Practice Address - Street 1:1638 DECKNER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-2640
Practice Address - Country:US
Practice Address - Phone:920-562-9058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163W00000X, 163WH0200X, 163WL0100X, 163WM0102X, 163WW0101X, 176B00000X, 261QB0400X, 261QR1300X
WI31-049176B00000X
WI176B00000X
WI107888-030367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty
No163WM0102XNursing Service ProvidersRegistered NurseMaternal NewbornGroup - Single Specialty
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, AmbulatoryGroup - Single Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Single Specialty
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health