MEDICARE: FORT WAYNE DOULAS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174N00000X	Lactation Consultant (Non-RN)

General Provider Information

NPI Number	:	1043196876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WAYNE DOULAS, LLC

Provider Business Mailing Address
First Line	:	407 AIRPORT NORTH OFFICE PARK STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-782-4666
Fax Number	:	800-776-4346

Provider Business Practice Location Address
First Line	:	407 AIRPORT NORTH OFFICE PARK STE A
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-782-4666
Fax Number	:	800-776-4346

Authorized Official
Title or Position	:	OWNER
Name	:	AMY SICKELS
Credential	:	IBCLC
Telephone Number	:	260-782-4666

Provider Enumeration Date	:	08/15/2025
Last Update Date	:	08/15/2025

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