Healthcare Provider Details

I. General information

NPI: 1770249237
Provider Name (Legal Business Name): HEALTH ATLAST WICHITA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10111 E 21ST ST N STE 315
WICHITA KS
67206-3581
US

IV. Provider business mailing address

10111 E 21ST ST N STE 315
WICHITA KS
67206-3581
US

V. Phone/Fax

Practice location:
  • Phone: 316-807-0835
  • Fax: 316-330-6704
Mailing address:
  • Phone: 316-807-0835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSIKA RICHARDSON-COOKS
Title or Position: DIRECTOR OF OPERATIONS
Credential: RN
Phone: 316-806-0176