MEDICARE: BREANNE NICOLE SHULTS CDM

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	176B00000X	Midwife

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	69	OTHER	AK	CERTIFIED DIRECT ENTRY MIDWIFE

General Provider Information

NPI Number	:	1316246127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNE NICOLE SHULTS CDM

Provider Business Mailing Address
First Line	:	2150 S. NISSEN DRIVE
Second Line	:
City	:	PALMER
State	:	AK
Zip	:	99645
Country	:	US
Telephone Number	:	907-982-5723
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 S NISSEN DR
Second Line	:
City	:	PALMER
State	:	AK
Zip	:	99645-9069
Country	:	US
Telephone Number	:	907-982-5723
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	04/01/2011

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