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General NPI Number Information
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NPI Number | 1851717797
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Entity Type | Organization
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Legal Business Name | WELLNESS CLINIC AND MEDICAL SPA LLC
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Dates
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Enumeration Date | 03/17/2014
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Last Update Date | 10/30/2019
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Provider Practice Location Address
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Address Line | 128 W MAIN ST
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City | PURCELL
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State | OK
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Zip | 73080-4220
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Country | US
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Telephone | 405-527-4704
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Fax | 405-527-5976
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Provider Business Mailing Address
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Address Line | PO BOX 269031
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City | OKLAHOMA CITY
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State | OK
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Zip | 73126-9031
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Country | US
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Telephone | 877-485-4474
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Fax | 405-527-5976
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Authorized Official
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Title or Position | NURSE PRACTITIONER, OWNER
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Name | MS. DIANE DEWBRE
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Credential | APRN-GNP
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Telephone | 405-527-4704
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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 | 49456
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License Number State | OK
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