MEDICARE: INTENTIONAL WELLNESS SOLUTIONS

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1275172462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENTIONAL WELLNESS SOLUTIONS

Provider Business Mailing Address
First Line	:	30 1ST AVE NE STE 7
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-1515
Country	:	US
Telephone Number	:	763-400-8177
Fax Number	:	304-301-3047

Provider Business Practice Location Address
First Line	:	30 1ST AVE NE STE 7
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-1515
Country	:	US
Telephone Number	:	763-400-8177
Fax Number	:	304-301-3047

Authorized Official
Title or Position	:	OWNER/NURSE PRACTITIONER
Name	:	JAMIE J ANDERSON
Credential	:	FNP-C, PMHNP-BC
Telephone Number	:	612-232-2917

Provider Enumeration Date	:	01/06/2020
Last Update Date	:	03/22/2023

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