=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902503451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2023
-----------------------------------------------------
Last Update Date | 11/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 S THOMPSON ST STE 213
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-6941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-275-3520
-----------------------------------------------------
Fax | 479-335-3405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 S THOMPSON ST STE 213
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72764-6941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-275-3520
-----------------------------------------------------
Fax | 479-335-3405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, APRN
-----------------------------------------------------
Name | MS. TAYLOR BEAUREGARD KELAMIS
-----------------------------------------------------
Credential | APRN, FNP-C
-----------------------------------------------------
Telephone | 479-275-3520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------