Basic Information
| Provider Information | |||||||||
| NPI: | 1568009140 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRATED WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5016 N UNIVERSITY ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616144763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174910355 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5016 N UNIVERSITY ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616144763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174910355 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2019 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | KIRYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | FNP-C, FPA, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2174910355 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP-C, FPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.