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NPI Code Detail

MEDICARE: WELLNESS SOURCE LLC

MEDICARE: WELLNESS SOURCE LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133VN1006XMetabolic Nutrition Registered Dietitian
2133VN1201XObesity and Weight Management Nutrition Registered Dietitian
3163WP0807XChild & Adolescent Psychiatric/Mental Health Registered Nurse
4163WP0808XPsychiatric/Mental Health Registered Nurse
5207RA0401XAddiction Medicine (Internal Medicine) Physician
6363LA2200XAdult Health Nurse Practitioner
7363LF0000XFamily Nurse Practitioner
8363LP0808XPsychiatric/Mental Health Nurse Practitioner
9363LW0102XWomen's Health Nurse Practitioner
10133V00000XRegistered Dietitian

General Provider Information

NPI Number : 1114420320
Entity Type Code : Organization
Provider Name (Legal Business Name) : WELLNESS SOURCE LLC
Provider Business Mailing Address
First Line : 4301 GARDEN CITY DR STE 304
Second Line :
City : HYATTSVILLE
State : MD
Zip : 20785-6105
Country : US
Telephone Number : 301-235-0060
Fax Number :
Provider Business Practice Location Address
First Line : 4301 GARDEN CITY DR STE 304
Second Line :
City : HYATTSVILLE
State : MD
Zip : 20785-6105
Country : US
Telephone Number : 301-235-0060
Fax Number :
Authorized Official
Title or Position : MEDICAL DIRECTOR
Name : MARSHALEE GEORGE
Credential :
Telephone Number : 301-235-0060
Provider Enumeration Date : 03/14/2018
Last Update Date : 05/04/2022

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