=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013528017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL WELLNESS CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2020
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 COMMERCIAL CENTER DR STE 1
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72364-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-636-9218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 COMMERCIAL CENTER DR STE 1
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72364-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-636-9218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MRS. KRISTY ANNE WHITED
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 870-636-9218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------