Healthcare Provider Details

I. General information

NPI: 1851152458
Provider Name (Legal Business Name): FRAICHE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 CEDAR PT
DALLAS GA
30132-1096
US

IV. Provider business mailing address

59 CEDAR PT
DALLAS GA
30132-1096
US

V. Phone/Fax

Practice location:
  • Phone: 404-578-1204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: SHELLEY ANDERSON
Title or Position: CEO
Credential: PA
Phone: 678-823-5699