Healthcare Provider Details

I. General information

NPI: 1134988553
Provider Name (Legal Business Name): SACRED HEALING WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4652 LAWRENCEVILLE HWY NW STE 101
LILBURN GA
30047-3623
US

IV. Provider business mailing address

3870 PEACHTREE INDUSTRIAL BLVD STE 340
DULUTH GA
30096-1474
US

V. Phone/Fax

Practice location:
  • Phone: 678-665-2046
  • Fax: 470-567-5644
Mailing address:
  • Phone: 678-665-2046
  • Fax: 470-567-5644

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
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA NADINE ALLEN
Title or Position: OWNER
Credential: FNP
Phone: 678-665-2046