Healthcare Provider Details

I. General information

NPI: 1578318598
Provider Name (Legal Business Name): MEADOWLARK MIND & BODY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 CENTER ST STE 1
EVANSTON WY
82930-3400
US

IV. Provider business mailing address

913 CENTER ST STE 1
EVANSTON WY
82930-3400
US

V. Phone/Fax

Practice location:
  • Phone: 307-300-5885
  • Fax:
Mailing address:
  • Phone: 307-300-5885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHEENA COLE
Title or Position: DIRECTOR OF PROVIDER SERVICES
Credential: BSHA
Phone: 402-898-1113