MEDICARE: WHOLEMIND WELLNESS AND PSYCHIARTY

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
2	363LW0102X	Women's Health Nurse Practitioner

General Provider Information

NPI Number	:	1467308304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLEMIND WELLNESS AND PSYCHIARTY

Provider Business Mailing Address
First Line	:	20731 HOLYOKE AVE
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9825
Country	:	US
Telephone Number	:	507-319-2879
Fax Number	:

Provider Business Practice Location Address
First Line	:	20731 HOLYOKE AVE
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9825
Country	:	US
Telephone Number	:	507-319-2879
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH NURSE PRACTTIONER
Name	:	FADUMO H HERSI
Credential	:	DNP/APRN
Telephone Number	:	507-319-2879

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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