Healthcare Provider Details

I. General information

NPI: 1659200699
Provider Name (Legal Business Name): BRECKENRIDGE WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N 4TH ST STE 6
FLAGSTAFF AZ
86004-1812
US

IV. Provider business mailing address

2615 N 4TH ST STE 6
FLAGSTAFF AZ
86004-1812
US

V. Phone/Fax

Practice location:
  • Phone: 928-549-0730
  • Fax:
Mailing address:
  • Phone: 928-549-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEATHER BRECKENRIDGE
Title or Position: MEDICAL DIRECTOR
Credential: FNP-C
Phone: 928-589-0730