Healthcare Provider Details

I. General information

NPI: 1962275552
Provider Name (Legal Business Name): ORIGINAL MAMI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 E PALO VERDE ST STE 10
GILBERT AZ
85296-1045
US

IV. Provider business mailing address

7 E PALO VERDE ST STE 10
GILBERT AZ
85296-1045
US

V. Phone/Fax

Practice location:
  • Phone: 480-618-7219
  • Fax: 480-885-2402
Mailing address:
  • Phone: 480-203-1136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE CELIS
Title or Position: OWNER
Credential: RN, IBCLC
Phone: 480-203-1136