Healthcare Provider Details

I. General information

NPI: 1851206668
Provider Name (Legal Business Name): TERRA BLUE WELLNESS AND COACHING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2643 LEEWOOD BLVD
MELBOURNE FL
32935-2839
US

IV. Provider business mailing address

2643 LEEWOOD BLVD
MELBOURNE FL
32935-2839
US

V. Phone/Fax

Practice location:
  • Phone: 321-312-9326
  • Fax:
Mailing address:
  • Phone: 321-312-9326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CHRYSTAL WALLS
Title or Position: OWNER
Credential: APRN
Phone: 321-312-9326