Healthcare Provider Details

I. General information

NPI: 1720994494
Provider Name (Legal Business Name): MARY CLAIRE WAGNER ICEA BIRTH DOULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11287 PUCKER ST
NILES MI
49120-9036
US

IV. Provider business mailing address

11287 PUCKER ST
NILES MI
49120-9036
US

V. Phone/Fax

Practice location:
  • Phone: 269-362-4306
  • Fax:
Mailing address:
  • Phone: 269-362-4306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: