MEDICARE: LAURA RICKETTS PFA BBD

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	374J00000X	Doula

General Provider Information

NPI Number	:	1952837122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA RICKETTS PFA BBD

Provider Business Mailing Address
First Line	:	408 S LAKEVIEW DR
Second Line	:
City	:	CROSS JUNCTION
State	:	VA
Zip	:	22625
Country	:	US
Telephone Number	:	540-514-1607
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 S LAKEVIEW DR
Second Line	:
City	:	CROSS JUNCTION
State	:	VA
Zip	:	22625-2478
Country	:	US
Telephone Number	:	540-514-1607
Fax Number	:

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

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	05/10/2017

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