Healthcare Provider Details

I. General information

NPI: 1992527683
Provider Name (Legal Business Name): ANOVA MED SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N MAIN ST
SHERIDAN WY
82801-2629
US

IV. Provider business mailing address

1125 LEOPARD ST
SHERIDAN WY
82801-4627
US

V. Phone/Fax

Practice location:
  • Phone: 307-752-1849
  • Fax:
Mailing address:
  • Phone: 307-752-1849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHEYLOH BLUEMEL
Title or Position: MANAGER
Credential: FNP-C
Phone: 307-461-0845