MEDICARE: DISTINCT CARE MENTAL HEALTH AND WELLNESS SERVICES 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1275496424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISTINCT CARE MENTAL HEALTH AND WELLNESS SERVICES LLC

Provider Business Mailing Address
First Line	:	207 WINNBROOK ST
Second Line	:
City	:	STAUNTON
State	:	VA
Zip	:	24401-9204
Country	:	US
Telephone Number	:	540-255-9729
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 WINNBROOK ST
Second Line	:
City	:	STAUNTON
State	:	VA
Zip	:	24401-9204
Country	:	US
Telephone Number	:	540-255-9729
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	MRS. LILIAN AZENABOR
Credential	:	APRN, PMHNP
Telephone Number	:	540-255-9729

Provider Enumeration Date	:	12/04/2025
Last Update Date	:	12/04/2025

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