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NPI Code Detail

MEDICARE: LEGACY WELLNESS PLLC

MEDICARE: LEGACY WELLNESS 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
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1912731712
Entity Type Code : Organization
Provider Name (Legal Business Name) : LEGACY WELLNESS PLLC
Provider Business Mailing Address
First Line : PO BOX 46
Second Line :
City : PEORIA
State : AZ
Zip : 85380-0046
Country : US
Telephone Number : 623-792-3584
Fax Number :
Provider Business Practice Location Address
First Line : 19841 N 27TH AVE STE 204
Second Line :
City : PHOENIX
State : AZ
Zip : 85027-4005
Country : US
Telephone Number : 623-792-3584
Fax Number :
Authorized Official
Title or Position : PROVIDER
Name : KRISTIN KELLY
Credential : FNP
Telephone Number : 623-792-3584
Provider Enumeration Date : 08/26/2024
Last Update Date : 08/26/2024

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Directions to “LEGACY WELLNESS PLLC ” Practice Location

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