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General NPI Number Information
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NPI Number | 1588451249
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Entity Type | Organization
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Legal Business Name | WELLVANA LLC
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Dates
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Enumeration Date | 04/24/2025
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Last Update Date | 04/24/2025
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Provider Practice Location Address
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Address Line | 2930 SSR-K
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City | O'FALLON
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State | MO
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Zip | 63368
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Country | US
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Telephone | 281-881-6293
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Fax |
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Provider Business Mailing Address
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Address Line | 405 KEDRON VALLEY CT
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City | SAINT CHARLES
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State | MO
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Zip | 63304-7635
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Country | US
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Telephone | 281-881-6293
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HEATHER DAVIS
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Credential | PT
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Telephone | 281-881-6293
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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