Provider Demographics
NPI:1326539628
Name:PEACEFUL SOURCE MIDWIFERY LLC
Entity Type:Organization
Organization Name:PEACEFUL SOURCE MIDWIFERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBB
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:317-519-7661
Mailing Address - Street 1:1139 CANTERBURY CT.
Mailing Address - Street 2:UNIT B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-519-7661
Mailing Address - Fax:317-927-8620
Practice Address - Street 1:1139 CANTERBURY CT.
Practice Address - Street 2:UNIT B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-519-7661
Practice Address - Fax:317-927-8620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000274A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty