MEDICARE: SOUL SERENE WELLNESS AND MEDSPA 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	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1851118772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL SERENE WELLNESS AND MEDSPA LLC

Provider Business Mailing Address
First Line	:	5835 CAMPBELLTON RD SW STE 103
Second Line	:
City	:	SOUTH FULTON
State	:	GA
Zip	:	30331-8014
Country	:	US
Telephone Number	:	404-549-2505
Fax Number	:

Provider Business Practice Location Address
First Line	:	5835 CAMPBELLTON RD SW STE 103
Second Line	:
City	:	SOUTH FULTON
State	:	GA
Zip	:	30331-8014
Country	:	US
Telephone Number	:	404-549-2505
Fax Number	:

Authorized Official
Title or Position	:	OWNER/NURSE PRACTITIONER
Name	:	SHERDINA HOBSON
Credential	:	MSN, ANP-BC, CRNP
Telephone Number	:	404-549-2505

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	11/28/2024

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