=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649207507
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARBARA SHAKER WAX CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 03/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 MAIN ST
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02301-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-559-6699
-----------------------------------------------------
Fax | 508-583-4649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 MAIN ST
-----------------------------------------------------
City | BROCKTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02301-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-559-6699
-----------------------------------------------------
Fax | 508-559-5073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number | 124599
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------