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General NPI Number Information
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NPI Number | 1639836000
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Entity Type | Organization
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Legal Business Name | ETERNITY WELLNESS 22, LLC
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Dates
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Enumeration Date | 11/19/2021
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Last Update Date | 04/18/2024
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Provider Practice Location Address
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Address Line | 1636 POPPS FERRY RD STE 234
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City | BILOXI
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State | MS
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Zip | 39532-2279
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Country | US
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Telephone | 888-777-2671
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Fax | 228-641-2499
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Provider Business Mailing Address
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Address Line | 1636 POPPS FERRY RD STE 234
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City | BILOXI
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State | MS
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Zip | 39532-2279
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Country | US
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Telephone | 228-641-2449
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Fax | 228-641-2499
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Authorized Official
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Title or Position | NURSE PRACTITIONER, OWNER
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Name | TAWANA CHANELL RAYMOND
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Credential | FNP-C, PMHNP-BC
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Telephone | 228-641-2449
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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