Provider Demographics
NPI:1336139757
Name:BLUE MOON MIDWIVES LLC, PA
Entity Type:Organization
Organization Name:BLUE MOON MIDWIVES LLC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:CNM
Authorized Official - Phone:207-739-2800
Mailing Address - Street 1:176 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5643
Mailing Address - Country:US
Mailing Address - Phone:207-739-2800
Mailing Address - Fax:207-739-2877
Practice Address - Street 1:176 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5643
Practice Address - Country:US
Practice Address - Phone:207-739-2800
Practice Address - Fax:207-739-2877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER030353367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty