MEDICARE: WELLNESS FAMILY HEALTH NP, P.C.

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	363LF0000X	Family Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841903192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS FAMILY HEALTH NP, P.C.

Provider Business Mailing Address
First Line	:	708 BAYSIDE CT
Second Line	:
City	:	SOUTH AMBOY
State	:	NJ
Zip	:	08879-1981
Country	:	US
Telephone Number	:	347-987-1038
Fax Number	:

Provider Business Practice Location Address
First Line	:	1424 RICHMOND AVE, STE C
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-1527
Country	:	US
Telephone Number	:	646-763-4574
Fax Number	:	718-701-8103

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	DR. TSZHODERRICK LUM
Credential	:	DNP
Telephone Number	:	646-763-4574

Provider Enumeration Date	:	01/03/2023
Last Update Date	:	04/11/2023

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