Healthcare Provider Details

I. General information

NPI: 1659161842
Provider Name (Legal Business Name): WILD MOTHER PATH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12821 JACKS LN
PINEVILLE NC
28134-6430
US

IV. Provider business mailing address

12821 JACKS LN
PINEVILLE NC
28134-6430
US

V. Phone/Fax

Practice location:
  • Phone: 704-268-9194
  • Fax:
Mailing address:
  • Phone: 704-268-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: KAITLYN BLANCHE MARIE FOSTER
Title or Position: MEMBER
Credential: NP, RN
Phone: 704-268-9194