Healthcare Provider Details

I. General information

NPI: 1104677095
Provider Name (Legal Business Name): BE WELL ADULT, NP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 LAKELAND AVE UNIT 9
BOHEMIA NY
11716-2174
US

IV. Provider business mailing address

1461 LAKELAND AVE UNIT 9
BOHEMIA NY
11716-2174
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-8224
  • Fax: 631-585-7575
Mailing address:
  • Phone: 631-467-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NICOLE FLEMMING
Title or Position: BILLING AND CREDENTIALING MANAGER
Credential: CPC,CRC,CPC,CBCS,CMA
Phone: 843-640-9342