# COUNTRY MIDWIFE LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Country Midwife
- **Organization subpart:** No

## Provider details

- **NPI number:** 1255505525
- **Authorized official:** MISS STACY L VANDENPUT LM, CPM (MIDWIFE, MANAGER)
- **Authorized official phone:** (920) 562-9058

## Contact information

- **Practice address:** 1638 DECKNER AVE, SUITE A, GREEN BAY, WI 54302-2640
- **Practice address phone:** (920) 562-9058
- **Mailing address:** 1638 DECKNER AVE, SUITE A, GREEN BAY, WI 54302-2640
- **Mailing address phone:** (920) 562-9058

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 163W00000X | Registered Nurse | — | NULL | — |
| 163W00000X | Registered Nurse | — | — | — |
| 163WH0200X | Home Health Registered Nurse | — | NULL | — |
| 163WH0200X | Home Health Registered Nurse | — | — | — |
| 163WL0100X | Lactation Consultant (Registered Nurse) | — | NULL | — |
| 163WL0100X | Lactation Consultant (Registered Nurse) | — | — | — |
| 163WM0102X | Maternal Newborn Registered Nurse | — | NULL | — |
| 163WM0102X | Maternal Newborn Registered Nurse | — | — | — |
| 163WW0101X | Ambulatory Women's Health Care Registered Nurse | — | NULL | — |
| 163WW0101X | Ambulatory Women's Health Care Registered Nurse | — | — | — |
| 176B00000X | Midwife | 31-049 | WI | — |
| 176B00000X | Midwife | — | NULL | — |
| 176B00000X | Midwife | — | — | — |
| 261QB0400X | Birthing Clinic/Center | — | NULL | — |
| 261QR1300X | Rural Health Clinic/Center | — | NULL | — |
| 367A00000X | Advanced Practice Midwife | 107888-030 | WI | Yes |

## Other

- **Enumeration date:** 04/17/2008
- **Last updated:** 11/05/2010