MEDICARE: MOMMAS LIGHT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1104773647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMMAS LIGHT LLC

Provider Business Mailing Address
First Line	:	3501 FORTUNA CT
Second Line	:
City	:	HUNTINGTOWN
State	:	MD
Zip	:	20639-4202
Country	:	US
Telephone Number	:	717-433-3617
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 FORTUNA CT
Second Line	:
City	:	HUNTINGTOWN
State	:	MD
Zip	:	20639-4202
Country	:	US
Telephone Number	:	717-433-3617
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SPEECH PATHOLOGIST
Name	:	JENNIFER ANDERSON
Credential	:	M.S., CCC-SLP
Telephone Number	:	717-433-3617

Provider Enumeration Date	:	03/13/2026
Last Update Date	:	03/13/2026

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