Healthcare Provider Details

I. General information

NPI: 1063143659
Provider Name (Legal Business Name): JOURNEY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 S EAGLE RD STE 180
MERIDIAN ID
83642-9246
US

IV. Provider business mailing address

1965 S EAGLE RD STE 180
MERIDIAN ID
83642-9246
US

V. Phone/Fax

Practice location:
  • Phone: 986-666-3866
  • Fax: 986-666-3038
Mailing address:
  • Phone: 986-666-3866
  • Fax: 986-666-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRIA MWANGA
Title or Position: MEDICAL DIRECTOR
Credential: DNP, FNP-C
Phone: 208-380-9906