Healthcare Provider Details

I. General information

NPI: 1316881931
Provider Name (Legal Business Name): IASO MIND & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4640 LIPSCOMB ST NE STE 13
PALM BAY FL
32905-2986
US

IV. Provider business mailing address

491 FELLENZ ST SW
PALM BAY FL
32908-4785
US

V. Phone/Fax

Practice location:
  • Phone: 321-223-0143
  • Fax: 689-444-5626
Mailing address:
  • Phone: 321-223-0143
  • 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: ANGELA ROSE WHITTAMORE
Title or Position: PMHNP/OWNER
Credential: PMHNP
Phone: 321-747-4331