Healthcare Provider Details

I. General information

NPI: 1134713159
Provider Name (Legal Business Name): MIND & BODY WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2021
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3603 W STAGE COACH TRL
SHELBY NC
28150-9598
US

IV. Provider business mailing address

3603 W STAGE COACH TRL
SHELBY NC
28150-9598
US

V. Phone/Fax

Practice location:
  • Phone: 910-387-3840
  • Fax: 704-703-9668
Mailing address:
  • Phone: 704-476-9144
  • Fax: 704-703-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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 TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LEISTEY ELISE TINDALL
Title or Position: OWNER
Credential:
Phone: 910-387-3840