Healthcare Provider Details

I. General information

NPI: 1104007368
Provider Name (Legal Business Name): WAREHAM NURSE MIDWIVES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MAIN STREET
WAREHAM MA
02571
US

IV. Provider business mailing address

332 MAIN STREET
WAREHAM MA
02571
US

V. Phone/Fax

Practice location:
  • Phone: 508-295-3088
  • Fax: 508-295-2079
Mailing address:
  • Phone: 508-295-3088
  • Fax: 508-295-2079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number143429
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number143429
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number275550
License Number StateMA

VIII. Authorized Official

Name: LOUISE RACINE BASTARACHE
Title or Position: PRESIDENT
Credential: CNM MS NP
Phone: 508-295-3088