MEDICARE: PHOENIX HEALTH & WELLNESS NURSING CORP

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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1295615094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HEALTH & WELLNESS NURSING CORP

Provider Business Mailing Address
First Line	:	PO BOX 1144
Second Line	:
City	:	RANCHO MIRAGE
State	:	CA
Zip	:	92270-1144
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	73845 VAN GOGH DR
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-4523
Country	:	US
Telephone Number	:	442-353-0488
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RUSSELL SIMON
Credential	:
Telephone Number	:	442-353-0488

Provider Enumeration Date	:	09/03/2025
Last Update Date	:	09/03/2025

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