Healthcare Provider Details

I. General information

NPI: 1477347615
Provider Name (Legal Business Name): DIVERSE WELLNESS SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7580 NW 5TH ST UNIT 15614
PLANTATION FL
33318-8427
US

IV. Provider business mailing address

7580 NW 5TH ST UNIT 15614
PLANTATION FL
33318-8427
US

V. Phone/Fax

Practice location:
  • Phone: 888-212-1949
  • Fax: 888-281-6026
Mailing address:
  • Phone: 888-212-1949
  • Fax: 888-281-6026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KYNDALL NYESCHELLE MAMMAH
Title or Position: PROVIDER/OWNER
Credential: FNP
Phone: 888-212-1949