=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194416982
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEEPLES HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 07/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 US HIGHWAY 80 SW
-----------------------------------------------------
City | POOLER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31322-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-508-6414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 761 MIDDLE COUNTRY RD
-----------------------------------------------------
City | SELDEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11784-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-736-4064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTING
-----------------------------------------------------
Name | JENNY NEWCOMB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-736-4064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------