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General NPI Number Information
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NPI Number | 1457667180
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Entity Type | Organization
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Legal Business Name | FULL BLOOM MIDWIFERY
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Dates
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Enumeration Date | 08/18/2010
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Last Update Date | 08/18/2010
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Provider Practice Location Address
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Address Line | 722 N MAIN ST
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City | FORT BRAGG
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State | CA
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Zip | 95437-3017
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Country | US
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Telephone | 707-964-8808
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Fax | 707-964-8808
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Provider Business Mailing Address
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Address Line | 722 N MAIN ST
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City | FORT BRAGG
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State | CA
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Zip | 95437-3017
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Country | US
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Telephone | 707-964-8808
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Fax | 707-964-8808
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Authorized Official
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Title or Position | PARTNER
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Name | MS. JENNA BRETON
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Credential | MSN, CNM
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Telephone | 707-964-8808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0050X
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Taxonomy Name | Non-Surgical Family Planning Clinic/Center
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License Number | 1784
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License Number State | CA
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