MEDICARE: MIND BODY SOUL AND SPIRIT MBSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1184438350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND BODY SOUL AND SPIRIT MBSS

Provider Business Mailing Address
First Line	:	2269 HIALEAH ST NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2650
Country	:	US
Telephone Number	:	321-244-7067
Fax Number	:

Provider Business Practice Location Address
First Line	:	2269 HIALEAH ST NE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2650
Country	:	US
Telephone Number	:	321-244-7067
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VERONA ESTELLA HAUGHTON
Credential	:	NP
Telephone Number	:	321-244-7067

Provider Enumeration Date	:	02/06/2025
Last Update Date	:	08/15/2025

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