=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215473749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERIDITH MIKULICH MPH, CNM, RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2017
-----------------------------------------------------
Last Update Date | 09/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIVERSITY ASSOCIATES IN OB/GYN HSC LEVEL 9, ROOM 020
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-222-0412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1559
-----------------------------------------------------
City | STONY BROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11794-4142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-222-0412
-----------------------------------------------------
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 | 001764
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 001764
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------