=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245103795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIPHANT HOLISTIC HEALTH AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2025
-----------------------------------------------------
Last Update Date | 09/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 W BRANDON BLVD STE 204
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-203-7399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11214 E DR MLK JR BLVD STE 101
-----------------------------------------------------
City | SEFFNER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AR
-----------------------------------------------------
Name | THRAESE BROWN
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 813-679-6592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------