Healthcare Provider Details

I. General information

NPI: 1679232508
Provider Name (Legal Business Name): GOLDEN PHOENIX WELLNESS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BROADWAY STE 200-4502
ALBANY NY
12207-2236
US

IV. Provider business mailing address

600 BROADWAY STE 200-4502
ALBANY NY
12207-2236
US

V. Phone/Fax

Practice location:
  • Phone: 214-405-5556
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE FULLER
Title or Position: CO-CEO
Credential:
Phone: 214-405-5556