=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750206496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDIVERSE HEALTH & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2026
-----------------------------------------------------
Last Update Date | 08/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2570 GRACIE DR STE 107
-----------------------------------------------------
City | BALDWIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54002-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-977-2312
-----------------------------------------------------
Fax | 715-487-3131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | W4401 STATE ROAD 29
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54767-8311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-977-2312
-----------------------------------------------------
Fax | 715-487-3131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA STOIBER
-----------------------------------------------------
Credential | AGACNP-BC
-----------------------------------------------------
Telephone | 715-977-2312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------