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General NPI Number Information
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NPI Number | 1942005335
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Entity Type | Organization
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Legal Business Name | WELLNESS PROVIDER SERVICES LLC
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Dates
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Enumeration Date | 02/18/2025
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 780 LYNNHAVEN PKWY STE 400
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-7332
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Country | US
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Telephone | 757-650-1762
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Fax |
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Provider Business Mailing Address
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Address Line | 780 LYNNHAVEN PKWY STE 400
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City | VIRGINIA BEACH
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State | VA
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Zip | 23452-7332
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Country | US
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Telephone | 757-650-1762
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TERA STANISTREET
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Credential | APRN
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Telephone | 757-650-1762
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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