Provider Demographics
NPI:1356073852
Name:BLUE RIVER HEALTH & WELLNESS, PLLC
Entity Type:Organization
Organization Name:BLUE RIVER HEALTH & WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-577-2727
Mailing Address - Street 1:PO BOX 10739
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0739
Mailing Address - Country:US
Mailing Address - Phone:928-577-2727
Mailing Address - Fax:888-498-4639
Practice Address - Street 1:1520 E HAMMER LN STE 104
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6665
Practice Address - Country:US
Practice Address - Phone:602-315-0211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23375081OtherCORPORATION ID