Healthcare Provider Details

I. General information

NPI: 1083754634
Provider Name (Legal Business Name): TRILLIUM WOMANCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 AUTUMN AVENUE
MEMPHIS TN
38112
US

IV. Provider business mailing address

2610 AUTUMN AVENUE
MEMPHIS TN
38112
US

V. Phone/Fax

Practice location:
  • Phone: 901-292-5354
  • Fax: 901-452-8088
Mailing address:
  • Phone: 901-292-5354
  • Fax: 901-452-8088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAPN 10920
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberCPM0000000030.
License Number StateTN

VIII. Authorized Official

Name: MS. AMY KRISTINE STEWART-BANBURY
Title or Position: OWNER
Credential: CPM-TN
Phone: 901-292-5354