Healthcare Provider Details

I. General information

NPI: 1760088272
Provider Name (Legal Business Name): LATAVIA MARIE WELLS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/09/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3191 HARBOR BLVD STE A
PORT CHARLOTTE FL
33952-6755
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 941-883-4518
  • Fax:
Mailing address:
  • Phone: 239-223-2751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN9542926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: