MEDICARE: WAYFARER WELLNESS CLINIC, 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
1	261QP2300X	Primary Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9344892	OTHER	FL	STATE LICENSE
2	1043718521	OTHER	FL	NPI

General Provider Information

NPI Number	:	1265367825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAYFARER WELLNESS CLINIC, LLC

Provider Business Mailing Address
First Line	:	6322 ROWAN RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34653-3400
Country	:	US
Telephone Number	:	727-777-9355
Fax Number	:	800-339-7093

Provider Business Practice Location Address
First Line	:	6322 ROWAN RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34653-3400
Country	:	US
Telephone Number	:	727-777-9355
Fax Number	:	800-339-7093

Authorized Official
Title or Position	:	OWNER/NURSE PRACTITIONER
Name	:	DR. JILLIAN AUDREYA FAWN STUPER
Credential	:	DNP, MSN, FNP-C
Telephone Number	:	727-777-9355

Provider Enumeration Date	:	06/16/2026
Last Update Date	:	06/16/2026

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