=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376814335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE HEALTH AND HORMONE CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2012
-----------------------------------------------------
Last Update Date | 02/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1731 BOYSON RD
-----------------------------------------------------
City | HIAWATHA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52233-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-363-0033
-----------------------------------------------------
Fax | 319-363-4411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1731 BOYSON RD
-----------------------------------------------------
City | HIAWATHA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52233-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-363-0033
-----------------------------------------------------
Fax | 319-363-4411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE GRAY
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 319-329-8132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | H-117587
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------