Provider Demographics
NPI:1558764464
Name:PREMIER HEALTH & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:PREMIER HEALTH & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:O
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-304-2421
Mailing Address - Street 1:PO BOX 14149
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70898-4149
Mailing Address - Country:US
Mailing Address - Phone:225-930-0060
Mailing Address - Fax:225-952-9075
Practice Address - Street 1:300 HIGHLAND BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4600
Practice Address - Country:US
Practice Address - Phone:601-304-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853759164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty