Healthcare Provider Details

I. General information

NPI: 1598409468
Provider Name (Legal Business Name): WELL NOURISHED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 YOUNGFIELD ST STE 101
GOLDEN CO
80401-0208
US

IV. Provider business mailing address

2801 YOUNGFIELD ST STE 101
GOLDEN CO
80401-0208
US

V. Phone/Fax

Practice location:
  • Phone: 720-241-2489
  • Fax:
Mailing address:
  • Phone: 720-241-2489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HOPE MANNING
Title or Position: PA-C
Credential: PA-C, CAQ-PSYCH
Phone: 720-241-2489