Healthcare Provider Details

I. General information

NPI: 1679701064
Provider Name (Legal Business Name): COASTAL MEDICAL & WELLNESS CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3257 SE SALERNO RD SUITE 3
STUART FL
34997-6736
US

IV. Provider business mailing address

3257 SE SALERNO RD SUITE 3
STUART FL
34997-6736
US

V. Phone/Fax

Practice location:
  • Phone: 772-286-5277
  • Fax: 772-286-9478
Mailing address:
  • Phone: 772-286-5277
  • Fax: 772-286-9478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8186
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9174934
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME104153
License Number StateFL

VIII. Authorized Official

Name: LYNNE E ATWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 772-286-5277