| Document Date: 2011-07-19 14:22:40
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City Completed / Louisiana Medicaid / Nurse-Midwife / Baton Rouge / / Company ACNM Certification Council Inc. / / Facility Employ Electronic Data Interchange of Claims / / IndustryTerm bank / bank letterhead / Web Application / / Organization ACNM Certification Council / Molina Medicaid Solutions Provider Enrollment Unit / Internal Revenue Service / American Midwifery Certification Board / / Person Form / / Position physician / Attorney / Certified Nurse Midwife / Midwife / Individual Certified Nurse / Certified Nurse / Nurse / / ProvinceOrState Louisiana / / URL www.lamedicaid.com / /
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PROVIDER TYPE SPECIFIC PACKET/CHECKLIST (Louisiana Medicaid Program) Certified Nurse Midwife (Individual)