MEDICARE: INTEGRATIVE HEALTH AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1972155539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE HEALTH AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	2666 S 2000 E STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1721
Country	:	US
Telephone Number	:	801-691-7064
Fax Number	:	801-855-7998

Provider Business Practice Location Address
First Line	:	2666 S 2000 E STE 101
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1721
Country	:	US
Telephone Number	:	801-631-9363
Fax Number	:	801-855-7998

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	EMILY VAN OS
Credential	:	PMHNP-BC, FNP-C
Telephone Number	:	801-691-7064

Provider Enumeration Date	:	07/14/2019
Last Update Date	:	10/23/2020

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