Healthcare Provider Details

I. General information

NPI: 1487232302
Provider Name (Legal Business Name): MARK THOMAS HEPWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 1ST AVE E STE 1
SPENCER IA
51301-4330
US

IV. Provider business mailing address

1200 1ST AVE E STE 1
SPENCER IA
51301-4330
US

V. Phone/Fax

Practice location:
  • Phone: 712-264-6228
  • Fax:
Mailing address:
  • Phone: 712-264-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberG162956
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: