Healthcare Provider Details

I. General information

NPI: 1699649681
Provider Name (Legal Business Name): GAIA GROVE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

8315 SW 24TH ST
MIAMI FL
33155-1138
US

IV. Provider business mailing address

10521 SW 88TH ST STE E106
MIAMI FL
33176-1554
US

V. Phone/Fax

Practice location:
  • Phone: 305-934-8460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANNA VILLASUSO
Title or Position: OWNER
Credential: APRN
Phone: 305-934-8460