Healthcare Provider Details

I. General information

NPI: 1467186288
Provider Name (Legal Business Name): SELF WELLNESS & HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 07/16/2022
Certification Date: 07/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 MACARTHUR ST
WINSTON SALEM NC
27107-6124
US

IV. Provider business mailing address

4134 MACARTHUR ST
WINSTON SALEM NC
27107-6124
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACY GAFFNEY
Title or Position: MEMBER/ ORGANIZER
Credential: FNP-BC
Phone: 336-399-7716