Provider Demographics
NPI:1851797617
Name:BLUE MOON MIDWIFERY LLC
Entity Type:Organization
Organization Name:BLUE MOON MIDWIFERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:KIRKWOOD WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:715-308-9540
Mailing Address - Street 1:113 WHEELOCK PKWY E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-3934
Mailing Address - Country:US
Mailing Address - Phone:715-308-9540
Mailing Address - Fax:
Practice Address - Street 1:113 WHEELOCK PKWY E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-3934
Practice Address - Country:US
Practice Address - Phone:715-308-9540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty