MEDICARE: HAWTHORN WELLNESS CLINIC PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1083469720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAWTHORN WELLNESS CLINIC PLLC

Provider Business Mailing Address
First Line	:	320 LOCUST DR
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-7801
Country	:	US
Telephone Number	:	319-621-9466
Fax Number	:

Provider Business Practice Location Address
First Line	:	565 CAMERON WAY STE 103
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-4868
Country	:	US
Telephone Number	:	319-499-5410
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRACTIONER
Name	:	ALLISON MARIE DONOVAN
Credential	:	NP
Telephone Number	:	319-621-9466

Provider Enumeration Date	:	04/17/2024
Last Update Date	:	04/17/2024

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