=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023834926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL HEALING PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2176 E FRANKLIN RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-9374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-391-5046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16520 MULBERRY LN
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83687-8492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-888-0449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | CAROLYN ANN NUGENT
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 360-888-0449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------