Healthcare Provider Details

I. General information

NPI: 1073814851
Provider Name (Legal Business Name): AWAKEN WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 MINSTREL WAY STE 160
COLUMBIA MD
21045-5336
US

IV. Provider business mailing address

7130 MINSTREL WAY STE 160
COLUMBIA MD
21045-5336
US

V. Phone/Fax

Practice location:
  • Phone: 410-312-9922
  • Fax:
Mailing address:
  • Phone: 410-312-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L STUKEY
Title or Position: LICENSE ACUPUNCTURIST
Credential: L.AC.
Phone: 410-312-9922