Healthcare Provider Details

I. General information

NPI: 1013395284
Provider Name (Legal Business Name): MOMMY & BABY WELLNESS PATH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2015
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CLARK CIR
SOUTH DENNIS MA
02660-2508
US

IV. Provider business mailing address

11 CLARK CIR
SOUTH DENNIS MA
02660-2508
US

V. Phone/Fax

Practice location:
  • Phone: 201-468-2245
  • Fax:
Mailing address:
  • Phone: 201-468-2245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberRN2276431
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberRN2276431
License Number StateMA

VIII. Authorized Official

Name: MARY LOUISE DOYLE
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 201-468-2245