Organization
BLUE RIVER HEALTH & WELLNESS, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE ANN ROBERTS FNP (OWNER)
(928) 577-2727
Entity
Organization
Contact information
Practice address
1520 E HAMMER LN STE 104, FORT MOHAVE, AZ 86426-6665
(602) 315-0211
Mailing address
PO BOX 10739, FORT MOHAVE, AZ 86427-0739
(928) 577-2727
(888) 498-4639
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
—
—
363LF0000X
Family Nurse Practitioner
Primary
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
363LP2300X
Primary Care Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
23375081
CORPORATION ID
AZ
Enumeration date
06/24/2022
Last updated
06/24/2022
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