Healthcare Provider Details

I. General information

NPI: 1376185538
Provider Name (Legal Business Name): WILDER MIDWIFERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 NE 3RD ST
MCMINNVILLE OR
97128-6219
US

IV. Provider business mailing address

3262 MAYFIELD PL N
KEIZER OR
97303-6034
US

V. Phone/Fax

Practice location:
  • Phone: 405-596-7326
  • Fax:
Mailing address:
  • Phone: 405-596-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name: JESSICA WEST VINING
Title or Position: CERTIFIED PROFESSIONAL MIDWIFE
Credential: CPM, LDM
Phone: 405-596-7326