Healthcare Provider Details

I. General information

NPI: 1053657775
Provider Name (Legal Business Name): EARTHEN VESSELS NURSE MIDWIFERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2012
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 AIRPORT NORTH OFFICE PARK
FORT WAYNE IN
46825-6702
US

IV. Provider business mailing address

1755 COUNTY ROAD 36
AUBURN IN
46706-9404
US

V. Phone/Fax

Practice location:
  • Phone: 260-704-7166
  • Fax: 260-357-0282
Mailing address:
  • Phone: 260-704-7166
  • Fax: 260-357-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number09000220A
License Number StateIN

VIII. Authorized Official

Name: MRS. JANIS L CHRISSIKOS
Title or Position: CERTIFIED NURSE MIDWIFE
Credential: CNM
Phone: 260-704-7166