Healthcare Provider Details

I. General information

NPI: 1225949365
Provider Name (Legal Business Name): LEGACY WHOLE HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 COVE BEND DR
TAMPA FL
33613-2752
US

IV. Provider business mailing address

3212 COVE BEND DR
TAMPA FL
33613-2752
US

V. Phone/Fax

Practice location:
  • Phone: 813-945-9821
  • Fax: 813-742-5412
Mailing address:
  • Phone: 813-945-9821
  • Fax: 813-742-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. STANIA AYANNA DEJESUS
Title or Position: OWNER
Credential: DO
Phone: 646-662-7578