Provider Demographics
NPI:1962049932
Name:WHOLELIFE FAMILY WELLNESS CLINIC OF PROVIDENCE PLLC
Entity type:Organization
Organization Name:WHOLELIFE FAMILY WELLNESS CLINIC OF PROVIDENCE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, FNP-C, DNP
Authorized Official - Phone:435-213-3597
Mailing Address - Street 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:169 N GATEWAY DR. SUITE 170
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:435-213-3597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty