Healthcare Provider Details

I. General information

NPI: 1821399460
Provider Name (Legal Business Name): LABOR OF LOVE MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 S. KNIK GOOSE BAY ROAD
WASILLA AK
99654
US

IV. Provider business mailing address

PO BOX 874486
WASILLA AK
99587-4486
US

V. Phone/Fax

Practice location:
  • Phone: 907-841-2565
  • Fax: 888-862-1422
Mailing address:
  • Phone: 907-841-2565
  • Fax: 888-862-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License NumberFBC-014
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License NumberNM0044
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1571125
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: MS. PEGGY JEAN HALSEY
Title or Position: DIRECTOR
Credential: CDM, CPM
Phone: 907-841-2565