=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760298566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIRTHROOT COMMUNITY DOULA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 650 EAST AVE STE 106
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16503-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-449-6200
-----------------------------------------------------
Fax | 814-205-0755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 650 EAST AVE STE 106
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16503-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-449-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. TICA NICOLE NICKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-449-6200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174N00000X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Non-RN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 374J00000X
-----------------------------------------------------
Taxonomy Name | Doula
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------