Provider Demographics
NPI:1639836000
Name:ETERNITY WELLNESS 22, LLC
Entity Type:Organization
Organization Name:ETERNITY WELLNESS 22, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:CHANELL
Authorized Official - Last Name:RAYMOND
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:228-641-2449
Mailing Address - Street 1:1636 POPPS FERRY RD STE 234
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2279
Mailing Address - Country:US
Mailing Address - Phone:228-641-2449
Mailing Address - Fax:228-641-2499
Practice Address - Street 1:1636 POPPS FERRY RD STE 234
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2279
Practice Address - Country:US
Practice Address - Phone:888-777-2671
Practice Address - Fax:228-641-2499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-19
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty