Healthcare Provider Details

I. General information

NPI: 1104074459
Provider Name (Legal Business Name): WHOLISTIC HEALTH FOR WOMEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 CURRY ROAD
ROSENBURG OR
97471-8508
US

IV. Provider business mailing address

909 CURRY RD
ROSEBURG OR
97471-8508
US

V. Phone/Fax

Practice location:
  • Phone: 619-260-0810
  • Fax: 541-802-0787
Mailing address:
  • Phone: 619-260-0810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License NumberRN456541NP5830
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC5147
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC51231
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN456541NP5830
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN456541NP5830
License Number StateCA

VIII. Authorized Official

Name: MS. SUZANN A. GAGE
Title or Position: PRESIDENT AND EXECUTIVE DIRECTOR
Credential: APNP, WHNP, LAC
Phone: 619-260-0810