=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548096142
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIORITY HEALTH NORTHWEST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2024
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 NORRIS PLACE
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51301-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-580-4570
-----------------------------------------------------
Fax | 712-580-4573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 NORRIS PL
-----------------------------------------------------
City | SPENCER
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51301-3411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-580-4570
-----------------------------------------------------
Fax | 712-580-4573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | PEYTON R HANTELMAN
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 712-209-6642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------