=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538982921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRTUWELL TELEHEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 E LINCOLNWAY # 5038
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82001-4851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-715-8031
-----------------------------------------------------
Fax | 313-715-8031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3209 BIDDLE AVE
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-5917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-715-8031
-----------------------------------------------------
Fax | 313-715-8031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MAYA KHALIL
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 313-715-8031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------