Healthcare Provider Details

I. General information

NPI: 1679252084
Provider Name (Legal Business Name): BEWELL- LIFESTYLE & FUNCTIONAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 MAIN ST
SMITHFIELD VA
23430-1346
US

IV. Provider business mailing address

10438 OAK SPRING RD
CARROLLTON VA
23314-4130
US

V. Phone/Fax

Practice location:
  • Phone: 434-294-2416
  • Fax:
Mailing address:
  • Phone: 434-294-2416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN MEISER
Title or Position: NURSE PRACTITIONER
Credential: RN, MSN, FNP-C
Phone: 434-294-2416