Provider Demographics
NPI:1356756944
Name:MODERN MELANATED MOTHERS
Entity type:Organization
Organization Name:MODERN MELANATED MOTHERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LACTATION DOULA
Authorized Official - Prefix:
Authorized Official - First Name:DENIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-520-0696
Mailing Address - Street 1:109 WILLOWICK DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-1725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 WILLOWICK DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-1725
Practice Address - Country:US
Practice Address - Phone:678-520-0696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care