=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104773498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MI'BELLA WELLNESS CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2026
-----------------------------------------------------
Last Update Date | 03/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 TRIPP RD
-----------------------------------------------------
City | ELLINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06029-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-351-1525
-----------------------------------------------------
Fax | 860-893-0232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 182 TRIPP RD
-----------------------------------------------------
City | ELLINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06029-3642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-351-1525
-----------------------------------------------------
Fax | 860-893-0232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT/OWNER
-----------------------------------------------------
Name | CARLY MELISSA MUNIZ
-----------------------------------------------------
Credential | MUNIZ
-----------------------------------------------------
Telephone | 413-351-1525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------