=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184488439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MENTAL HEALTH AND WELLNESS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 S 1ST ST APT A
-----------------------------------------------------
City | WILLIAMS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86046-2561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-632-8076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 S 1ST ST STE A
-----------------------------------------------------
City | WILLIAMS
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-389-1529
-----------------------------------------------------
Fax | 928-635-4495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRACTITIONER
-----------------------------------------------------
Name | LYNN COOPER JOHNSON
-----------------------------------------------------
Credential | PMHNP
-----------------------------------------------------
Telephone | 928-389-1529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------