Provider Demographics
NPI:1295246932
Name:TRINITY HEALTH & WELLNESS FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:TRINITY HEALTH & WELLNESS FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DIPAOLA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:603-731-5907
Mailing Address - Street 1:3869 CHESAPEAKE PL
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-4343
Mailing Address - Country:US
Mailing Address - Phone:603-731-5907
Mailing Address - Fax:
Practice Address - Street 1:45 CAPRI BLVD STE F
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5657
Practice Address - Country:US
Practice Address - Phone:928-234-1177
Practice Address - Fax:928-733-6259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-21
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9834261QP2300X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1669836748Medicaid