=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003505983
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTH AND WELLNESS PSYCHIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2023
-----------------------------------------------------
Last Update Date | 05/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 E BASELINE RD STE 204
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85234-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-888-5917
-----------------------------------------------------
Fax | 480-401-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 E BASELINE RD STE 204
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85234-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-888-5917
-----------------------------------------------------
Fax | 480-401-0816
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP
-----------------------------------------------------
Name | ANTHONY OLORUNSOLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-888-5917
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------