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General NPI Number Information
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NPI Number | 1023844909
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Entity Type | Organization
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Legal Business Name | GUMTREE MENTAL HEALTH & WELLNESS
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Dates
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Enumeration Date | 09/09/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 520 FULLERTON RD STE B
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City | SWANSEA
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State | IL
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Zip | 62226-2901
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Country | US
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Telephone | 618-277-0006
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Fax |
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Provider Business Mailing Address
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Address Line | 405 N LINCOLN AVE
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City | O FALLON
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State | IL
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Zip | 62269-1322
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Country | US
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Telephone | 813-838-2707
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | KYRIA A BUCHANAN
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Credential | PMHNP-BC, APRN
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Telephone | 813-838-2707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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