Provider Demographics
NPI:1306245246
Name:MOONRISE MIDWIFERY AND WOMEN'S HEALTH, LLC
Entity type:Organization
Organization Name:MOONRISE MIDWIFERY AND WOMEN'S HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CNM, ANP
Authorized Official - Phone:505-681-7769
Mailing Address - Street 1:822 BASIN RD
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1037
Mailing Address - Country:US
Mailing Address - Phone:505-681-7769
Mailing Address - Fax:877-299-7953
Practice Address - Street 1:822 BASIN RD
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1037
Practice Address - Country:US
Practice Address - Phone:505-681-7769
Practice Address - Fax:877-299-7953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-16
Last Update Date:2014-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1003461261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service