Healthcare Provider Details

I. General information

NPI: 1265367825
Provider Name (Legal Business Name): WAYFARER WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 07/04/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 ROWAN RD
NEW PORT RICHEY FL
34653-3400
US

IV. Provider business mailing address

6322 ROWAN RD
NEW PORT RICHEY FL
34653-3400
US

V. Phone/Fax

Practice location:
  • Phone: 727-777-9355
  • Fax: 800-339-7093
Mailing address:
  • Phone: 727-777-9355
  • Fax: 800-339-7093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JILLIAN AUDREYA FAWN STUPER
Title or Position: OWNER/NURSE PRACTITIONER
Credential: DNP, MSN, FNP-C
Phone: 727-777-9355