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General NPI Number Information
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NPI Number | 1568009140
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Entity Type | Organization
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Legal Business Name | INTEGRATED WELLNESS
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Dates
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Enumeration Date | 12/03/2019
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Last Update Date | 12/03/2019
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Provider Practice Location Address
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Address Line | 5016 N UNIVERSITY ST STE 104
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City | PEORIA
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State | IL
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Zip | 61614-4763
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Country | US
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Telephone | 217-491-0355
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Fax |
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Provider Business Mailing Address
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Address Line | 5016 N UNIVERSITY ST STE 104
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City | PEORIA
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State | IL
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Zip | 61614-4763
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Country | US
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Telephone | 217-491-0355
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Fax |
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Authorized Official
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Title or Position | FNP-C, FPA, OWNER
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Name | KIRYN EVANS
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Credential | FNP-C, FPA
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Telephone | 217-491-0355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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