Healthcare Provider Details

I. General information

NPI: 1780048124
Provider Name (Legal Business Name): DEGRAZIA WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 HILLCREST PARK DR SUITE 100
MEDFORD OR
97504-7693
US

IV. Provider business mailing address

3210 HILLCREST PARK DR SUITE 100
MEDFORD OR
97504-7693
US

V. Phone/Fax

Practice location:
  • Phone: 541-494-8888
  • Fax: 541-494-1300
Mailing address:
  • Phone: 541-494-8888
  • Fax: 541-494-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number201500652NP-PP
License Number StateOR

VIII. Authorized Official

Name: MRS. KARISSA STULTS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 541-890-5217