Healthcare Provider Details

I. General information

NPI: 1902578479
Provider Name (Legal Business Name): SELF WELLNESS & HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 MACARTHUR ST
WINSTON SALEM NC
27107-6124
US

IV. Provider business mailing address

3601 EBERT CT APT 200C
WINSTON SALEM NC
27127-5790
US

V. Phone/Fax

Practice location:
  • Phone: 336-399-7716
  • Fax:
Mailing address:
  • Phone: 336-399-7716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACY GAFFNEY
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 336-399-7716