Healthcare Provider Details

I. General information

NPI: 1396496675
Provider Name (Legal Business Name): EDEN MIDWIFERY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

IV. Provider business mailing address

890 BELTLINE RD
SPRINGFIELD OR
97477-1091
US

V. Phone/Fax

Practice location:
  • Phone: 541-515-6556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: CRYSTAL MASSEY
Title or Position: DIRECTOR
Credential: CNM
Phone: 541-510-5155