Healthcare Provider Details

I. General information

NPI: 1003213612
Provider Name (Legal Business Name): MOTHER EARTH YOGA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11257 42ND AVE
PLEASANT PRAIRIE WI
53158-3842
US

IV. Provider business mailing address

11257 42ND AVE
PLEASANT PRAIRIE WI
53158-3842
US

V. Phone/Fax

Practice location:
  • Phone: 508-789-7718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State

VIII. Authorized Official

Name: HOLLY ANN PECKSKAMP
Title or Position: BIRTH DOULA
Credential: DOULA
Phone: 508-789-7718