MEDICARE: OLIVE BRANCH HEALTH AND 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	261QH0100X	Health Service Clinic/Center
2	163WG0100X	Gastroenterology Registered Nurse

General Provider Information

NPI Number	:	1316895865
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE BRANCH HEALTH AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	3018 N US HIGHWAY 301 STE 200
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-2271
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3018 N US HIGHWAY 301 STE 200
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-2271
Country	:	US
Telephone Number	:	813-679-5413
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PAULETTE VITAL-HERNE
Credential	:	APRN
Telephone Number	:	813-679-5413

Provider Enumeration Date	:	03/19/2026
Last Update Date	:	03/19/2026

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