MEDICARE: EVOLVE WELLNESS AND AESTHETICS 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	363LF0000X	Family Nurse Practitioner
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1942940812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE WELLNESS AND AESTHETICS PLLC

Provider Business Mailing Address
First Line	:	12650 N BEACH ST STE 114-946
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4256
Country	:	US
Telephone Number	:	214-843-0713
Fax Number	:

Provider Business Practice Location Address
First Line	:	12650 N BEACH ST STE 114-946
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4256
Country	:	US
Telephone Number	:	214-843-0713
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAYLA SEWELL
Credential	:	FNP-C
Telephone Number	:	214-843-0713

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	06/12/2024

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