=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669889473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERT BLOSSOM MIDWIFERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2014
-----------------------------------------------------
Last Update Date | 01/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4810 E HIGHWAY 90
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-335-1128
-----------------------------------------------------
Fax | 520-335-1132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4810 E HIGHWAY 90
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-335-1128
-----------------------------------------------------
Fax | 520-335-1132
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MISTY L. DECKER
-----------------------------------------------------
Credential | CNM
-----------------------------------------------------
Telephone | 520-335-1128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------