MEDICARE: MOM BABY

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	163WL0100X	Lactation Consultant (Registered Nurse)

General Provider Information

NPI Number	:	1174914097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOM BABY

Provider Business Mailing Address
First Line	:	1912 WEBSTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1828
Country	:	US
Telephone Number	:	610-322-4932
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 WEBSTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-1828
Country	:	US
Telephone Number	:	610-322-4932
Fax Number	:

Authorized Official
Title or Position	:	LACTATION CONSULTANT
Name	:	ROSALIE E KMIEC
Credential	:	RN, IBCLC
Telephone Number	:	610-322-4932

Provider Enumeration Date	:	02/13/2015
Last Update Date	:	02/13/2015

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