=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538852421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON HEALTH & WELLNESS SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2023
-----------------------------------------------------
Last Update Date | 05/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7375 EXECUTIVE PL
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-2278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-828-9006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7375 EXECUTIVE PL
-----------------------------------------------------
City | LANHAM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20706-2278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-828-9006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | EDITH EMELIFE
-----------------------------------------------------
Credential | MSN, FNP, CRNP
-----------------------------------------------------
Telephone | 240-381-5413
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------