Healthcare Provider Details

I. General information

NPI: 1053805382
Provider Name (Legal Business Name): SHERIDAN PEAK WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S. THURMOND ST.
SHERIDAN WY
82801
US

IV. Provider business mailing address

740 S. THURMOND ST.
SHERIDAN WY
82801
US

V. Phone/Fax

Practice location:
  • Phone: 307-683-6874
  • Fax: 415-559-4790
Mailing address:
  • Phone: 307-683-6874
  • Fax: 415-559-4790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number232
License Number StateWY

VIII. Authorized Official

Name: MISS JENNIFER LEE CLARK
Title or Position: CORPORATION OWNER
Credential: R.D.
Phone: 307-683-6874