Healthcare Provider Details

I. General information

NPI: 1033961669
Provider Name (Legal Business Name): PREMIER WELLNESS CONCIERGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 S PEBBLE BEACH BLVD STE 202C
SUN CITY CENTER FL
33573-5708
US

IV. Provider business mailing address

11823 TETRAFIN DR
RIVERVIEW FL
33579-4128
US

V. Phone/Fax

Practice location:
  • Phone: 813-954-0363
  • Fax: 813-644-5745
Mailing address:
  • Phone: 813-954-0363
  • Fax: 813-644-5745

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: MS. DIANA THERESA BURCHETT
Title or Position: PRACTITIONER
Credential: APRN
Phone: 941-807-1112