NPIMap

Organization Active NPI

Wholelife Family Wellness Clinic of Providence PLLC

  • Family Nurse Practitioner
  • Providence, UT
National Provider Identifier
1962049932
Registry record updated Mar 13, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
Legal business name
WHOLELIFE FAMILY WELLNESS CLINIC OF PROVIDENCE PLLC
Practice address
169 N Gateway Dr. Suite 170
Providence, UT 84332
Phone
(435) 213-3597
NPI assigned
Dec 9, 2019
Last updated
Mar 13, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 13, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Natalie Jean Gibson, APRN, FNP-C, DNPNPI 1528419330
Title
Co-Owner
Phone
(435) 213-3597

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X Primary

Addresses

Primary practice location

169 N Gateway Dr. Suite 170
Providence, UT 84332

Mailing address

274 N Main St
Logan, UT 84321-3915
Phone (435) 753-1600

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200324003049 UT Part B Supplier - Clinic/Group Practice 5193153294 Receives reassigned benefits from 9 practitioners
Practice locations: Providence, UT

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
46D2177918Wholelife Family Wellness Clinic of Providence169 N Gateway Drive, Suite 170, Providence, UT 84332Certificate of waiverJan 21, 2028

National Provider Directory

National Provider Directory

Locations

200 N Gateway Dr
#B
Providence, UT 84332
Phone (435) 213-3597

530 W 465 N
Ste 34
Providence, UT 84332

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1575849600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584057600000",
    "number": "1962049932",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "274 N MAIN ST",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843213915",
            "telephone_number": "435-753-1600",
            "fax_number": "435-753-9521"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "169 N GATEWAY DR. SUITE 170",
            "city": "PROVIDENCE",
            "state": "UT",
            "postal_code": "84332",
            "telephone_number": "435-213-3597"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WHOLELIFE FAMILY WELLNESS CLINIC OF PROVIDENCE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-09",
        "last_updated": "2020-03-13",
        "certification_date": "2020-03-13",
        "status": "A",
        "authorized_official_last_name": "GIBSON",
        "authorized_official_first_name": "NATALIE",
        "authorized_official_middle_name": "JEAN",
        "authorized_official_title_or_position": "CO-OWNER",
        "authorized_official_telephone_number": "435-213-3597",
        "authorized_official_credential": "APRN, FNP-C, DNP"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Providence, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.