Healthcare Provider Details

I. General information

NPI: 1417864380
Provider Name (Legal Business Name): EDEN INTEGRATIVE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 RT. 10
GILSUM NH
03448
US

IV. Provider business mailing address

135 SILENT WAY
KEENE NH
03431-4739
US

V. Phone/Fax

Practice location:
  • Phone: 603-338-8757
  • Fax:
Mailing address:
  • Phone: 603-338-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AUDRA J. WILSON
Title or Position: MANAGER/OWNER
Credential: MSN, APRN, FNP-C
Phone: 603-338-8757