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General NPI Number Information
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NPI Number | 1518798214
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Entity Type | Organization
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Legal Business Name | ILLUSIONS WELLNESS AND RECOVERY LLC
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Dates
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Enumeration Date | 08/13/2024
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 800 VIGINIA AVE STE 59 B
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City | FORT PIERCE
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State | FL
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Zip | 34982
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Country | US
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Telephone | 772-577-6323
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Fax |
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Provider Business Mailing Address
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Address Line | 800 VIGINIA AVE STE 59 B
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City | FORT PIERCE
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State | FL
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Zip | 34982
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Country | US
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Telephone | 772-577-6323
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NYDIA M WHITAKER
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Credential | ARNP
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Telephone | 723-577-6323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 163WG0000X
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Taxonomy Name | General Practice Registered Nurse
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License Number |
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License Number State |
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