Healthcare Provider Details

I. General information

NPI: 1962049932
Provider Name (Legal Business Name): WHOLELIFE FAMILY WELLNESS CLINIC OF PROVIDENCE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2019
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N GATEWAY DR. SUITE 170
PROVIDENCE UT
84332
US

IV. Provider business mailing address

274 N MAIN ST
LOGAN UT
84321-3915
US

V. Phone/Fax

Practice location:
  • Phone: 435-213-3597
  • Fax:
Mailing address:
  • Phone: 435-753-1600
  • Fax: 435-753-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: NATALIE JEAN GIBSON
Title or Position: CO-OWNER
Credential: APRN, FNP-C, DNP
Phone: 435-213-3597