Provider Demographics
NPI:1528419561
Name:NEW ERA WELLNESS, LLC
Entity Type:Organization
Organization Name:NEW ERA WELLNESS, LLC
Other - Org Name:NEW ERA WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:MYRTIS
Authorized Official - Middle Name:MARVELL-MCCAIN
Authorized Official - Last Name:AGEN-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP-BC
Authorized Official - Phone:410-775-6394
Mailing Address - Street 1:PO BOX 3237
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3745
Mailing Address - Country:US
Mailing Address - Phone:410-236-4969
Mailing Address - Fax:410-744-6520
Practice Address - Street 1:715 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1726
Practice Address - Country:US
Practice Address - Phone:410-236-4969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR157786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD056072300Medicaid