Healthcare Provider Details

I. General information

NPI: 1750206496
Provider Name (Legal Business Name): MEDIVERSE HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 GRACIE DR STE 107
BALDWIN WI
54002-4403
US

IV. Provider business mailing address

W4401 STATE ROAD 29
SPRING VALLEY WI
54767-8311
US

V. Phone/Fax

Practice location:
  • Phone: 715-977-2312
  • Fax: 715-487-3131
Mailing address:
  • Phone: 715-977-2312
  • Fax: 715-487-3131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JESSICA STOIBER
Title or Position: OWNER
Credential: AGACNP-BC
Phone: 715-977-2312