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General NPI Number Information
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NPI Number | 1366819310
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Entity Type | Organization
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Legal Business Name | LIFESPAN WELLNESS PLLC
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Dates
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Enumeration Date | 08/25/2015
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Last Update Date | 02/24/2016
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Provider Practice Location Address
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Address Line | 1404 N MAIN ST SUITE 101
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City | MERIDIAN
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State | ID
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Zip | 83642-2799
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Country | US
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Telephone | 208-888-6264
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Fax | 208-906-2363
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Provider Business Mailing Address
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Address Line | 1404 N MAIN ST SUITE 101
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City | MERIDIAN
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State | ID
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Zip | 83642-2799
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Country | US
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Telephone | 208-888-6264
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Fax | 208-906-2363
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Authorized Official
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Title or Position | OWNER/PSYCHIATRIC NP
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Name | MRS. REBEKAH DANIELLE NATION
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Credential | APRN
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Telephone | 770-324-7635
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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 | NP-1536A
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License Number State | ID
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