Healthcare Provider Details

I. General information

NPI: 1174389910
Provider Name (Legal Business Name): MIRACLE MOMENTS MIDWIFERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 S HILLSIDE ST
WICHITA KS
67211-4001
US

IV. Provider business mailing address

6526 S WARD PKWY
WICHITA KS
67217-5962
US

V. Phone/Fax

Practice location:
  • Phone: 316-361-6276
  • Fax:
Mailing address:
  • Phone: 620-480-0115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA NICOLE GOODELL
Title or Position: OWNER CNM
Credential: APRN CNM
Phone: 620-480-0115