=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275147910
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZON PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2020
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 699 WALNUT ST STE 400
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50309-3962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-381-6870
-----------------------------------------------------
Fax | 800-566-1259
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1185 W MOUNTAIN VIEW RD APT 3401
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-381-6870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DENIS KIPKEMOI DENIS
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 910-627-6174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------