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General NPI Number Information
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NPI Number | 1518630599
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Entity Type | Organization
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Legal Business Name | AWAKEN WELLNESS NC, LLC
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Dates
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Enumeration Date | 07/27/2021
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Last Update Date | 08/06/2021
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Provider Practice Location Address
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Address Line | 2529 RAEFORD RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28305-5098
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Country | US
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Telephone | 910-644-0588
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Fax | 725-209-1671
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Provider Business Mailing Address
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Address Line | 5964 DALTON RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28314-1022
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Country | US
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Telephone | 910-973-2689
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Fax | 725-209-1671
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MRS. TANYA GIBBS
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Credential | FNP
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Telephone | 910-644-0588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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