Healthcare Provider Details

I. General information

NPI: 1013426204
Provider Name (Legal Business Name): MODERN MAMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 AQUAVIA RD
MEDFORD MA
02155-1002
US

IV. Provider business mailing address

21 AQUAVIA RD
MEDFORD MA
02155-1002
US

V. Phone/Fax

Practice location:
  • Phone: 860-919-5563
  • Fax: 617-765-7318
Mailing address:
  • Phone: 860-919-5563
  • Fax: 617-765-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: MRS. KARA LYNNE SCHAMELL
Title or Position: CO-MANAGER
Credential: CPM
Phone: 860-919-5563