Provider Demographics
NPI:1366819310
Name:LIFESPAN WELLNESS PLLC
Entity Type:Organization
Organization Name:LIFESPAN WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHIATRIC NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:NATION
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:770-324-7635
Mailing Address - Street 1:1404 N MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2799
Mailing Address - Country:US
Mailing Address - Phone:208-888-6264
Mailing Address - Fax:208-906-2363
Practice Address - Street 1:1404 N MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2799
Practice Address - Country:US
Practice Address - Phone:208-888-6264
Practice Address - Fax:208-906-2363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1536A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty