Basic Information
| Provider Information | |||||||||
| NPI: | 1851717797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLNESS CLINIC AND MEDICAL SPA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269031 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
| FaxNumber: | 4055275976 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PURCELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730804220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055274704 | ||||||||
| FaxNumber: | 4055275976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | DEWBRE | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4055274704 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | APRN-GNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 49456 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.