=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205187267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALIEET M CANOSA LICENSED MIDWIFE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2012
-----------------------------------------------------
Last Update Date | 09/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 726 SE 12TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33990-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-557-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 SE 12TH AVE
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33990-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-557-8052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number | MW257
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------