Healthcare Provider Details

I. General information

NPI: 1902724545
Provider Name (Legal Business Name): WILLFUL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4908 EVEREST RUN #302
PALMETTO FL
34221
US

IV. Provider business mailing address

7210 MANATEE AVE W # 1011
BRADENTON FL
34209-3439
US

V. Phone/Fax

Practice location:
  • Phone: 941-580-0213
  • Fax: 941-827-8971
Mailing address:
  • Phone: 941-580-0213
  • Fax: 941-827-8971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TANASIA THOMAS
Title or Position: PROVIDER
Credential: APRN
Phone: 941-580-2890