Provider Demographics
NPI:1083263503
Name:WELLNESS FOR LIFE FAMILY PRACTICE
Entity Type:Organization
Organization Name:WELLNESS FOR LIFE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TONIA
Authorized Official - Middle Name:LANETTE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:623-322-0099
Mailing Address - Street 1:20449 N LAKE PLEASANT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2707
Mailing Address - Country:US
Mailing Address - Phone:623-322-0099
Mailing Address - Fax:866-228-5038
Practice Address - Street 1:20449 N LAKE PLEASANT RD STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-2707
Practice Address - Country:US
Practice Address - Phone:623-322-0099
Practice Address - Fax:866-228-5038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-06
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty