Provider Demographics
NPI:1508582289
Name:ATHENA INTEGRATED CARE PLLC
Entity Type:Organization
Organization Name:ATHENA INTEGRATED CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:CLARE
Authorized Official - Last Name:FERTIG
Authorized Official - Suffix:
Authorized Official - Credentials:MSN,APRN,PMHNP,FNP
Authorized Official - Phone:712-266-3577
Mailing Address - Street 1:300 W BROADWAY STE 240
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-9028
Mailing Address - Country:US
Mailing Address - Phone:712-266-3577
Mailing Address - Fax:712-336-8541
Practice Address - Street 1:300 W BROADWAY STE 240
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-9028
Practice Address - Country:US
Practice Address - Phone:712-266-3577
Practice Address - Fax:712-336-8541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty