Blue River Health & Wellness, PLLC
Organization Active NPI Family Nurse Practitioner · Fort Mohave, AZ
NPI 1356073852 · NPPES record last updated Jun 24, 2022
Key facts
- NPI
- 1356073852
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- Legal business name
- BLUE RIVER HEALTH & WELLNESS, PLLC
- Practice address
- 1520 E Hammer LN Ste 104
Fort Mohave, AZ 86426-6665 - Phone
- (602) 315-0211
- NPI assigned
- Jun 24, 2022
- Organization subpart
- No
Authorized official
- Name
- Nicole Ann Roberts, FNP
- Title
- Owner
- Phone
- (928) 577-2727
Practitioners 4
-
Nicole Ann Roberts, FNP
-
Charles Raymond Stevens, M.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in AZ
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20220721001592 | AZ | Part B Supplier - Clinic/Group Practice | 8325429350 |
Receives reassigned benefits from 2 practitioners Practice locations: Fort Mohave, AZ |
National Provider Directory
Locations
5717 S Highway 95
Ste 4
Fort Mohave, AZ 86426
Phone (928) 577-2727
5717 S Highway 95
Ste 6
Fort Mohave, AZ 86426
Phone (928) 276-3049
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | |||
| Family Nurse Practitioner |
363LF0000X | Yes | ||
| Psychiatric/Mental Health Nurse Practitioner |
363LP0808X | |||
| Primary Care Nurse Practitioner |
363LP2300X |
Addresses
Primary practice location
1520 E Hammer LN Ste 104
Fort Mohave, AZ 86426-6665
Mailing address
PO Box 10739
Fort Mohave, AZ 86427-0739
Phone (928) 577-2727
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 23375081 | Other | AZ | CORPORATION ID |
Other providers in Fort Mohave, AZ
- Thomas Baughman
- Richard P Benedict
- Nathan Eric Beneze
- Donna Bennett
- Dayna Blake
- Blue Water Internal Medicine Associates P C
- Scott Irwin Boggs
- Jennifer Booze-Hawkes
- Eric Eugene Borofsky
- Larry Lee Bousquet II
All providers in Fort Mohave, AZ · Family Nurse Practitioner in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 24, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.