Healthcare Provider Details

I. General information

NPI: 1659192060
Provider Name (Legal Business Name): HEALTH AND WELLNESS PREMIUM SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 E TIFFANY DR STE 229
MANGONIA PARK FL
33407-3242
US

IV. Provider business mailing address

1710 E TIFFANY DR STE 229
MANGONIA PARK FL
33407-3242
US

V. Phone/Fax

Practice location:
  • Phone: 561-606-6023
  • Fax: 561-437-8410
Mailing address:
  • Phone: 561-247-3069
  • Fax: 561-437-8410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: KESANN K DORMAND
Title or Position: CEO
Credential:
Phone: 561-779-0728