=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003549692
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FEMMEWELL HOLDINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2022
-----------------------------------------------------
Last Update Date | 08/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 TOWN PLAZA AVE STE 240
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-5169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-395-5850
-----------------------------------------------------
Fax | 904-395-5852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 TOWN PLAZA AVE STE 240
-----------------------------------------------------
City | PONTE VEDRA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32081-5169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-395-5850
-----------------------------------------------------
Fax | 904-395-5852
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | ANDRIA PENNANT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 862-216-0089
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------