Healthcare Provider Details

I. General information

NPI: 1356137905
Provider Name (Legal Business Name): BEWELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 OAKRIDGE DR STE 100
FORT COLLINS CO
80525-7338
US

IV. Provider business mailing address

1315 OAKRIDGE DR STE 100
FORT COLLINS CO
80525-7338
US

V. Phone/Fax

Practice location:
  • Phone: 970-829-1129
  • Fax: 949-655-8678
Mailing address:
  • Phone: 970-829-1129
  • Fax: 949-655-8678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER E, KELLER DERAAD
Title or Position: CEO
Credential: APRN
Phone: 970-829-1129