Healthcare Provider Details

I. General information

NPI: 1477062826
Provider Name (Legal Business Name): LILA ROSE JENSEN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2017
Last Update Date: 09/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

1 WYOMING ST FL 1
DAYTON OH
45409-2722
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.412779
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAPRN.CNM.019323
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: