=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912511981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NURTURE MENTAL HEALTH & WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2020
-----------------------------------------------------
Last Update Date | 03/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 S KING ST STE 2A
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-8124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-502-3787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1045
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 83001-1045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-897-7821
-----------------------------------------------------
Fax | 919-551-7458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP
-----------------------------------------------------
Name | DANIELLE LUNGELOW
-----------------------------------------------------
Credential | APRN PMHNP-BC
-----------------------------------------------------
Telephone | 910-502-3787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------