Provider Demographics
NPI:1073062972
Name:WHOLEHEARTED FUNCTIONAL MEDICINE
Entity Type:Organization
Organization Name:WHOLEHEARTED FUNCTIONAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMBITO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:360-457-5139
Mailing Address - Street 1:430 E LAURIDSEN BLVD
Mailing Address - Street 2:212
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7978
Mailing Address - Country:US
Mailing Address - Phone:360-457-5139
Mailing Address - Fax:
Practice Address - Street 1:430 E LAURIDSEN BLVD
Practice Address - Street 2:212
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7978
Practice Address - Country:US
Practice Address - Phone:360-457-5139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP300006177261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service