MEDICARE: MIFAWNWY CARLSON L.M.

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	MW00000061	WA

General Provider Information

NPI Number	:	1417002353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIFAWNWY CARLSON L.M.

Provider Business Mailing Address
First Line	:	12270 OLALLA VALLEY RD SE
Second Line	:
City	:	OLALLA
State	:	WA
Zip	:	98359-9748
Country	:	US
Telephone Number	:	253-857-6359
Fax Number	:	253-857-6359

Provider Business Practice Location Address
First Line	:	12270 OLALLA VALLEY RD SE
Second Line	:
City	:	OLALLA
State	:	WA
Zip	:	98359-9748
Country	:	US
Telephone Number	:	253-857-6359
Fax Number	:	253-857-6359

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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Directions to “ MIFAWNWY CARLSON L.M.” Practice Location

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