Provider Demographics
NPI:1386023265
Name:MIND BODY NURSE PRACTITIONER INC
Entity Type:Organization
Organization Name:MIND BODY NURSE PRACTITIONER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRILEE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:951-966-7730
Mailing Address - Street 1:1347 HUCKLEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-4219
Mailing Address - Country:US
Mailing Address - Phone:951-966-7730
Mailing Address - Fax:417-890-9127
Practice Address - Street 1:1347 HUCKLEBERRY LN
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-4219
Practice Address - Country:US
Practice Address - Phone:951-966-7730
Practice Address - Fax:417-890-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-25
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000404363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty