Provider Demographics
NPI:1568009140
Name:INTEGRATED WELLNESS
Entity Type:Organization
Organization Name:INTEGRATED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C, FPA, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, FPA
Authorized Official - Phone:217-491-0355
Mailing Address - Street 1:5016 N UNIVERSITY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4763
Mailing Address - Country:US
Mailing Address - Phone:217-491-0355
Mailing Address - Fax:
Practice Address - Street 1:5016 N UNIVERSITY ST STE 104
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4763
Practice Address - Country:US
Practice Address - Phone:217-491-0355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty