=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346121951
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2025
-----------------------------------------------------
Last Update Date | 09/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 KINGSLEY LAKE DR STE 703
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-800-4003
-----------------------------------------------------
Fax | 904-800-5003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 KINGSLEY LAKE DR STE 703
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32092-3045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-800-4003
-----------------------------------------------------
Fax | 904-800-5003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BISONA YEBA BENNETT
-----------------------------------------------------
Credential | DNP, APRN, FNP-C
-----------------------------------------------------
Telephone | 904-800-4003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------