MEDICARE: SUNRISE WELLNESS SOLUTION PLLC

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	261QI0500X	Infusion Therapy Clinic/Center
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1407527203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNRISE WELLNESS SOLUTION PLLC

Provider Business Mailing Address
First Line	:	5287 S HIGHWAY 95 STE I
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9220
Country	:	US
Telephone Number	:	928-577-2024
Fax Number	:	970-788-1820

Provider Business Practice Location Address
First Line	:	5287 S HIGHWAY 95 STE I
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9220
Country	:	US
Telephone Number	:	928-577-2024
Fax Number	:	970-788-1820

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	LISA ANN STANLEY
Credential	:	APRN
Telephone Number	:	660-723-0953

Provider Enumeration Date	:	09/22/2021
Last Update Date	:	10/25/2023

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