MEDICARE: IASO MIND & WELLNESS LLC

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	:	1316881931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IASO MIND & WELLNESS LLC

Provider Business Mailing Address
First Line	:	491 FELLENZ ST SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32908-4785
Country	:	US
Telephone Number	:	321-223-0143
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 LIPSCOMB ST NE STE 13
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-2986
Country	:	US
Telephone Number	:	321-223-0143
Fax Number	:	689-444-5626

Authorized Official
Title or Position	:	PMHNP/OWNER
Name	:	ANGELA ROSE WHITTAMORE
Credential	:	PMHNP
Telephone Number	:	321-747-4331

Provider Enumeration Date	:	04/15/2026
Last Update Date	:	04/15/2026

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