Provider Demographics
NPI:1659013548
Name:PROFESSIONAL MENTAL HEALTH WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL MENTAL HEALTH WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RICKMAN-SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:850-447-4644
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:HOSFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32334-0443
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10564 NW SR 20 SUITE #2
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321
Practice Address - Country:US
Practice Address - Phone:850-447-4644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty