Provider Demographics
NPI:1639823040
Name:STORMY'S PRIMARY CARE AND WELLNESS MEDSPA LLC
Entity Type:Organization
Organization Name:STORMY'S PRIMARY CARE AND WELLNESS MEDSPA LLC
Other - Org Name:STORMYS PRIMARY CARE & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STORMY
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:MCBRIDE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:305-934-8667
Mailing Address - Street 1:400 LESLIE DR APT 1014
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-2910
Mailing Address - Country:US
Mailing Address - Phone:786-809-1855
Mailing Address - Fax:305-990-8832
Practice Address - Street 1:20200 W DIXIE HWY STE 805B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1920
Practice Address - Country:US
Practice Address - Phone:786-809-1855
Practice Address - Fax:305-990-8832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-05
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty