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General NPI Number Information
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NPI Number | 1407349665
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Entity Type | Organization
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Legal Business Name | ISAIAH 58 HEALTH & WELLNESS CENTER
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Dates
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Enumeration Date | 06/12/2018
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Last Update Date | 12/16/2019
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Provider Practice Location Address
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Address Line | 494 MAPLE AVE
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City | FORT PIERCE
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State | FL
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Zip | 34982-5949
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Country | US
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Telephone | 772-267-0516
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 12144
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City | FORT PIERCE
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State | FL
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Zip | 34979-2144
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | MRS. EVA BRYANT
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Credential | ARNP
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Telephone | 772-267-0516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | ARNP9338409
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License Number State | FL
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