Healthcare Provider Details

I. General information

NPI: 1750196549
Provider Name (Legal Business Name): KMD WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 N FEDERAL HWY
BOCA RATON FL
33487-1657
US

IV. Provider business mailing address

7601 N FEDERAL HWY
BOCA RATON FL
33487-1657
US

V. Phone/Fax

Practice location:
  • Phone: 561-783-8283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMY DAWN MOORE
Title or Position: CONTRACTING
Credential:
Phone: 503-819-6585