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1770399305 NPI number — WILD FIG, LLC

NPI Number: 1770399305
Health Care Provider/Practitioner: WILD FIG, LLC

Information about “1770399305” NPI (WILD FIG, LLC) exists in 1770399305 in HTML format HTML  |  1770399305 in plain Text format TXT  |  1770399305 in PDF (Portable Document Format) PDF  |  1770399305 in an XML format XML  formats.

NPI Number : 1770399305 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1770399305",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "WILD FIG, LLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 205",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BENTONVILLE",
    "MailingAddressStateName": "AR",
    "MailingAddressPostalCode": "72712-0205",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "618-554-8730",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "215 N COLLEGE AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "FAYETTEVILLE",
    "PracticeLocationAddressStateName": "AR",
    "PracticeLocationAddressPostalCode": "72701-4238",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "479-301-5290",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "12/09/2024",
    "LastUpdateDate": "12/09/2024",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "THOMAS",
    "AuthorizedOfficialFirstName": "CONNIE",
    "AuthorizedOfficialMiddleName": "MARIE",
    "AuthorizedOfficialTitle": "OWNER/NURSE PRACTITIONER",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DNP",
    "AuthorizedOfficialTelephoneNumber": "618-554-8730",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "261Q00000X",
          "TaxonomyName": "Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "261QM0850X",
          "TaxonomyName": "Adult Mental Health Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "261QM0855X",
          "TaxonomyName": "Adolescent and Children Mental Health Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "261QR0405X",
          "TaxonomyName": "Substance Use Disorder Rehabilitation Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "363LP0808X",
          "TaxonomyName": "Psychiatric/Mental Health Nurse Practitioner",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
      }
    }
  }
}
                
            

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