Healthcare Provider Details

I. General information

NPI: 1962650705
Provider Name (Legal Business Name): EAGLES NEST HOLISTIC MENTAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 1/2 MASS. SUITE 100
LAWRENCE KS
66044
US

IV. Provider business mailing address

32800 W 91ST TERRACE
DESOTO KS
66018
US

V. Phone/Fax

Practice location:
  • Phone: 913-530-2802
  • Fax: 913-530-2802
Mailing address:
  • Phone: 913-530-2802
  • Fax: 913-585-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number14-58010-092
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14-58010-092RN
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number74085APNR
License Number StateKS

VIII. Authorized Official

Name: LOIS ELLEN WILKINS
Title or Position: OWNER/PRESIDENT
Credential: APRN
Phone: 913-530-2802