=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093526956
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE WEIGHT LOSS AND WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2025
-----------------------------------------------------
Last Update Date | 01/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 MAIN ST STE 101
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-447-3125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54 MAIN ST STE 101
-----------------------------------------------------
City | LEOMINSTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01453-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 978-849-9950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER/ OWNER
-----------------------------------------------------
Name | VANESSA BAILEY
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 978-447-3125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------