Healthcare Provider Details

I. General information

NPI: 1134777576
Provider Name (Legal Business Name): WELLNESS LEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2019
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 GATEWAY DR STE 13
BEL AIR MD
21014-4268
US

IV. Provider business mailing address

1539 BLAKES LEGACY DR
BEL AIR MD
21014-1946
US

V. Phone/Fax

Practice location:
  • Phone: 410-286-1258
  • Fax:
Mailing address:
  • Phone: 817-319-6878
  • Fax: 443-231-3684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ISON
Title or Position: CO-OWNER
Credential: CRNP
Phone: 410-286-1258