Provider Demographics
NPI:1073038758
Name:WHITE MOUNTAIN WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:WHITE MOUNTAIN WELLNESS CLINIC LLC
Other - Org Name:WHITE MOUNTAIN WELLNESS CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, PMHNP
Authorized Official - Phone:928-233-6551
Mailing Address - Street 1:501 S CLARK RD # 7A
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-5655
Mailing Address - Country:US
Mailing Address - Phone:928-233-6551
Mailing Address - Fax:928-268-0143
Practice Address - Street 1:151 N WHITE MOUNTAIN RD STE E
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-5298
Practice Address - Country:US
Practice Address - Phone:480-886-4466
Practice Address - Fax:928-563-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-03
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2300X
363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care