Provider Demographics
NPI:1053805382
Name:SHERIDAN PEAK WELLNESS
Entity type:Organization
Organization Name:SHERIDAN PEAK WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:307-683-6874
Mailing Address - Street 1:740 S. THURMOND ST.
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-683-6874
Mailing Address - Fax:415-559-4790
Practice Address - Street 1:740 S. THURMOND ST.
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-683-6874
Practice Address - Fax:415-559-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 133VN1004X, 133VN1006X
WY232133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Multi-Specialty
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty