Healthcare Provider Details

I. General information

NPI: 1275264848
Provider Name (Legal Business Name): LAURELLA WELLNESS AND AESTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1954 US HIGHWAY 1 STE 115
ROCKLEDGE FL
32955-3761
US

IV. Provider business mailing address

1954 US HIGHWAY 1 STE 115
ROCKLEDGE FL
32955-3761
US

V. Phone/Fax

Practice location:
  • Phone: 321-338-7373
  • Fax: 321-631-8545
Mailing address:
  • Phone: 321-338-7373
  • Fax: 321-631-8545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN LAURELLA
Title or Position: CEO
Credential: APRN
Phone: 321-338-7373