MEDICARE: STATELINE MIDWIVES, 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	176B00000X	Midwife

General Provider Information

NPI Number	:	1861965451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATELINE MIDWIVES, LLC

Provider Business Mailing Address
First Line	:	8009 ANTIOCH RD
Second Line	:
City	:	SALEM
State	:	WI
Zip	:	53168-9525
Country	:	US
Telephone Number	:	847-533-5361
Fax Number	:

Provider Business Practice Location Address
First Line	:	8009 ANTIOCH RD
Second Line	:
City	:	SALEM
State	:	WI
Zip	:	53168-9525
Country	:	US
Telephone Number	:	847-533-5361
Fax Number	:

Authorized Official
Title or Position	:	MIDWIFE
Name	:	KRISTY HINZ
Credential	:	CPM, LM
Telephone Number	:	847-533-5361

Provider Enumeration Date	:	01/07/2019
Last Update Date	:	02/17/2019

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Directions to “STATELINE MIDWIVES, LLC ” Practice Location

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