Healthcare Provider Details

I. General information

NPI: 1427986256
Provider Name (Legal Business Name): TAILORED WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 WILLOW SPRINGS DR
JOHNSON CITY TN
37604-3221
US

IV. Provider business mailing address

1076 WILLOW SPRINGS DR
JOHNSON CITY TN
37604-3221
US

V. Phone/Fax

Practice location:
  • Phone: 865-363-5812
  • Fax:
Mailing address:
  • Phone: 865-363-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ANNA LEACH
Title or Position: PA
Credential: PA
Phone: 865-363-5812